LIBRARY OF CONGRESS. 



UNITED STATES OF AMERICA. 




A DICTIONARY 



OF 



TREATMENT; 



OR, 



THERAPEUTIC INDEX, 

INCLUDING 

MEDICAL AND SURGICAL THERAPEUTICS 



/! 



WILLIAM WHITLA, M.D. 



PROFESSOR OF MATERIA MEDICA AND THERAPEUTICS IN THE QUEEN'S COLLEGE, BELFAST J PHYSICIAN 

TO AND LECTURER ON CLINICAL MEDICINE, BELFAST ROYAL HOSPITAL; CONSULTING PHYSICIAN TO 

THE ULSTER HOSPITAL FOR WOMEN AND CHILDREN ; CONSULTING PHYSICIAN TO THE BELFAST 

OPHTHALMIC HOSPITAL; EXAMINER IN MATERIA MEDICA, ROYAL UNIVERSITY, IRELAND; 

EXAMINER IN MATERIA MEDICA, PHARMACEUTICAL SOCIETY, IRELAND; LATE EXAMINER 

IN MATERIA MEDICA AND THERAPEUTICS, UNIVERSITY OF GLASGOW ; AUTHOR OF 

PHARMACY, MATERIA MEDICA AND THERAPEUTICS, FIFTH EDITION; LATE 

MEMBER OF THE SENATE OF THE ROYAL UNIVERSITY, ETC. ETC. ETC. 



REVISED AND ADAPTED TO THE PHARMACOPOEIA 
OF THE UNITED STATES. 







PHILADELPHIA: 
LEA BKOTHEKS & CO. 

1892. 







•v\.C 



T?f\Aioi 



Entered according to Act of Congress, in the year 1892, by 

LEA BROTHERS & CO., 
, In the Office of the Librarian of Congress at Washington. 



DORNAN, PRINTER 



3tt SSemortam 



ALEXANDER GORDON, M.D., 

PKOFESSOR OF SURGERY IN THF. QUEEN'S COLLEGE, BELFAST, 1849-1886, 

A MAN OF RARE SINGLENESS OF PURPOSE AND OF 

UNFALTERING RECTITUDE, 

WHOSE GREAT ORIGINALITY AND PRACTICAL GENIUS 

MARKED AN EPOCH IN THE PROGRESS 

OF HIS ART 

%§X5 potume is Vebicaich 

BY 
HIS AFFECTIONATE PUPIL. 



PREFACE. 



The issue of each edition of the writer's work on Pharmacy, Materia 
Medica and Therapeutics, brought suggestions from many members of the 
profession, both teachers and practitiouers, upon the necessity of appending 
to it a Therapeutic Index, or Index of Diseases, for reference. With the 
view of acting upon these suggestions, and of furnishing the practitioner 
and student with a complete list of drugs suitable for the treatment of the 
various diseases, a Therapeutic Index, such as forms a portion of nearly 
every modern work on Materia Medica, was commenced. It soon, however, 
became evident that the practitioner or student would be assisted but little 
by a mere enumeration of the drugs suitable to the treatment of each affec- 
tion, unless the list was accompanied by some expression of opinion regarding 
the relative value of each drug, and of the different methods by which it 
might be employed. 

What was at first undertaken with the intention of being compressed into 
50 or 60 pages, has gradually grown into a volume of nearly 1000 pages, and 
the greatest difficulty was experienced at every point in keeping it within its 
present limits. The necessary condensation prohibited the discussion of 
pharmacological questions, and required the briefest reference to authori- 
ties, the writer having to remain content with giving the results of his own 
practical experience most concisely, before mentioning the various methods 
of treatment pursued successfully by others. 

Surgical questions are treated for the most part briefly, but the writer has 
frequently expressed his own opinions, formed during several years of prac- 
tice, when surgical methods formed the major part of his daily work, in 
conjunction with the late Professor Gordon. 

He expresses his indebtedness to Mr. Victor Fielding, whose careful cor- 
rection of the proof-sheets, and whose invaluable assistance in forwarding 
them through the press, made the issue of the present volume possible, 
amidst the interruptions and exactions of a laborious practice. 
8 College Square North, Belfast, December, 1891. 



TREATMENT OF DISEASES.- 



ABORTION. 

The treatment of this condition will depend to a large extent upon 
the period at which the physician finds the patient for the first time. 
Thus remedial agents may be demanded in the early months of preg- 
nancy at any of the following three stages : 

1. If there be a history of one or a series of previous abortions, it 
will be necessary to take measures to prevent the expulsion of the non- 
viable fetus, and tide over the dangerous period, though no threatening 
symptoms may be present. 

2. If symptoms of threatening abortion have already appeared. 

3. If the process of expulsion has already made a fair start, and 
there is no prospect of saving the fetus. 

1. If there be any reason to suspect syphilitic taint, a mild mercurial 
treatment should be commenced early and continued with circumspec- 
tion and with intermissions till after the sixth month. Salivation 
should never be produced, and it is comparatively easy to keep the 
patient under the influence of the drug without in any way reducing 
the system, or affecting the general health. -^ of a grain of bichloride 
of mercury three times daily in simple solution, or i grain of gray 
powder in pill, morning and night, may be continued for a long time. 
Should distinct evidences of recent syphilis be present, active treat- 
ment with much larger doses must be commenced without loss of time, 
and the ordinary antisyphilitic measures, as in the case of common 
syphilis, must be kept up. 

In dealing with a suspected tendency to abort in a patient who has 
had evidences of syphilis at a remote period, or in dealing with a case 
where a history is obtained of the disease in the male parent of many 
years previous, the physician may be able to form some estimate of the 
amount of mischief present by the way in which the remedy is borne, 
as will be mentioned under Syphilis. Where there is an active 
virus present, mercury often seems to spend its force upon it, and after 
the diseased condition is removed small doses appear to affect the 
system. 

In cases where the syphilis has been of long standing, and mercurial 
treatment had been at one time properly pushed, iodide of potassium 
in large doses, say 10 grains three times a day, may be given with 
advantage, and especially if there be any kidney mischief. Iodide of 

2 



10 ABORTION. 

potassium is also valuable in those cases where no history of syphilis 
can be obtained, and in those cases of so-called fatty degeneration of 
the placenta 5 grains three times a day, in pill, may be given for 
several weeks. In this latter class chlorate of potash in moderate 
doses is of decided value. It should not, however, be given in renal 
cases. 

Abortion having occurred once it is liable to be repeated, and some 
women acquire a habit of aborting— the expulsion of the fetus often 
occurring about the same time in each subsequent pregnancy. In 
these, as in the former class of cases, everything that might in any way 
cause excitement of the genital apparatus must be guarded against, 
and the dangerous period watched with care, and the patient kept in 
a state of absolute rest in bed at this time, and also at the time in 
which the ordinary menstrual flow might be expected to appear had 
she not become pregnant. After correcting flexions or versions, if 
present, the physician may keep the patient, who has acquired the 
habit of aborting, upon 3 grain doses of extract of viburnum, in the 
form of a pill, three times a day, or minute doses of mercury, or 
moderate doses of iodide of potassium or chlorate of potash, until the 
dreaded period has passes. Some authorities recommend small doses 
of ergot under these circumstances, but the writer never saw any 
benefit from such a plan. 

2. If abortion already threatens, as evidenced by slight hemorrhage 
or some pains, an attempt should always be made to prevent it. Ab- 
solute rest, by keeping the patient flat upon a firm bed with light 
covering, is essential. Opium or morphia is the main drug to be 
relied upon, and may be given freely — 1 grain of the watery extract 
of opium given every three, four or six hours as indicated. 3 to 5 
grains of acetate of lead have been used by some, and 10 minim doses 
of tincture of digitalis, but their value is doubtful except when given 
in combination with opium. Where opium fails, morphia, combined 
with digitalis, may succeed. The writer has seen uterine hemorrhage, 
stopped by this combination after the failure of all other remedies. 
Viburnum prunifolium or black haw r is in great repute in America, 
and may be given in doses of 1 to 3 drachms of the fluid extract, or it 
may be given as just mentioned in the pilular form. (See author's 
Materia Medica, fifth edition, p. 620.) 

The treatment of threatened abortion by minute doses of savin, 
ergot, and other supposed ecbolics, which are said to act as uterine 
sedatives when given in small doses, is to be condemned, as valuable 
time is lost by such an experiment. Hydrastis canadensis in 15 minim 
doses of the tincture is a valuable haemostatic, and may be tried alone 
or with opium. 

The physician must not place too much trust in internal remedies, 
and he should cease internal medication as soon as there is any evidence 
to show that the death of the fetus is probable. The danger of para- 
lyzing the uterus by means of large doses of sedatives whilst a dead 



ABORTION. 11 

fetus is contained in it, and the subsequent risk of septicemia, should 
be ever before him. Gentle and repeated examinations should be 
made from time to time as long as there is any bleeding. 

3. If it becomes evident that abortion cannot be prevented, and that 
the fetus is still out of reach, the proper course to pursue is to give 
ergot, 30 minims of the liquid extract, every three or four hours, and 
plug the vagina with cotton-wool through a speculum, or, as practised 
by Spiegelberg, who inserts by forceps pledgets of cotton-wool with the 
right hand, keeping two fingers of the left hand held wide apart in the 
vagina, the plugs are inserted without any attached strings ; each is 
greased with carbolized oil (1 in 5), and thrust well up against the os 
until the vagina is thoroughly packed. The vagina should be well 
washed out with an antiseptic lotion before plugging is commenced. 
The writer dispenses with this by freely covering the pledgets of wool 
with boric acid, and packing the spaces between the pledgets with this 
substance. The advantage of this is that the plug may not be re- 
moved for twenty-four to seventy-two hours, when the fetus and mem- 
branes almost always are found along with it. If by the end of three 
or four days the contents of the uterus are not expelled or within reach 
of the finger they should be removed, especially if hemorrhage to any 
extent be present. If this can be done by the finger thrust into the 
uterus no instrument should be employed, but sometimes the curette 
and scoop will be needed to remove all adherent portions of the mem- 
branes, after which the interior of the uterus should be swabbed with 
a strong carbolic solution, or with the pure acid, or with a solution of 
corrosive sublimate (1 : 5000). The plan of at once introducing the 
curette upon the first signs of hemorrhage, and of scraping the interior 
of the uterus and washing with sublimate solution, is not to be recom- 
mended as a routine practice. If symptoms of septic poisoning or of 
decomposition of the uterine contents set in, evacuation should be per- 
formed as soon as possible, and, if possible, always by the fingers, and 
the uterine cavity, cauterized freely with pure carbolic acid, and anti- 
septic lotions or injections must be frequently employed afterward till 
the danger is passed. 

Lawrence thus describes his method of dealing with a case of abor- 
tion which has gone beyond the expectant line of treatment — viz., rest, 
opium, etc. " Make the incomplete abortion complete by clearing out 
the uterus. Put the patient on her left side (Sims's position), wash 
out the vagina with carbolic lotion (1 : 100), pass a duck-bill speculum, 
take hold of the anterior lip of the cervix with Sims's hook, and pass 
up into the uterus a bougie of 20 grains of iodoform, then an antiseptic 
gelatin-coated sponge tent; retain this in the cervix uteri by a piece 
of iodoform wool in the vagina. In from twelve to twenty-four hours 
see the patient again. Remove the vaginal plug and sponge tent, both 
of which will be perfectly aseptic ; wash out the vagina with the car- 
bolic lotion, and now pass the finger into the uterus, and very likely 
you will be able to reach the fundus and clear out the contents. After 



12 ABSCESS. 

this wash out the uterus with carbolic lotion, and give directions for 
the vagina to be daily syringed. The great secret in the treatment is 
to clear out the uterus." Where the finger cannot reach the fundus it 
may be made to do so by retroverting the uterus through pressing the 
fundus toward the sacrum. Often when a catheter can be got through 
the os a stream of hot water may be injected. This may produce 
vigorous contractions which will expel the ovum, or the finger may be 
slipped through after the relaxation which afterward follows. When 
the curette is used, which should be seldom, a blunt one should be 
selected. Instruments for the extraction of the fetus or its membranes 
are not to be preferred to the finger. 

Where hemorrhage follows the expulsion of the fetus and its mem- 
branes, it is likely that some portion of the placenta is retained, and 
this should be removed by dilatation and the finger and a free stream 
of antiseptic liquid. 

After the expulsion or extraction of the fetus, the after-treatment 
should consist in the daily use of a vaginal antiseptic solution, rest in 
bed, milk diet, and the usual routine management indicated in the 
after-treatment of ordinary labor. As a rule, six or seven days' rest 
in bed will suffice for most cases in the absence of septic complications. 
Involution is not hastened by prolonged rest. 

ABSCESS. 

Where inflammatory action is present, constitutional or internal 
treatment may be tried to cause diminution or abortion of the suppur- 
ative process. Saline purges, large doses of quinine, 5 minim doses of 
tincture of belladonna, or y 1 ^ grain of sulphide of calcium in pill may 
be given every three or four hours. The results are, however, gener- 
ally disappointing. Locally, the suppurative stage may be cut short 
by rest, the application of alcoholic extract of belladonna, 1 drachm ; 
and glycerin, 10 drachms, smeared over the part. Poultices, by 
dilating the capillaries and small bloodvessels, relieve tension, and 
may effectually prevent suppuration. Cold applications, by causing a 
diminution in the size of the small vessels, may check the process by 
cutting short the increased supply of blood. Elevation of the part 
sometimes secures the same result. By covering over the surface of 
a poultice with extract of belladonna, and keeping the patient in a 
horizontal position, threatening mammary abscess may be often pre- 
vented. Pain is relieved by these means if suppuration supervenes. 
Local blood-letting often gives relief, and may check suppuration. 

If suppuration has already taken place, very warm poultices will 
hasten maturation, and hot fomentations act likewise. As soon, how- 
ever, as pus is evidently present, a free incision with a fine double-edged 
blade will relieve pain and tension, and limit the spread of inflamma- 
tion. By freezing the part with ether spray the pain of the incision 
may be prevented. The author finds that, by smearing the part 



ABSCESS. 13 

lightly over with the cork or stopper of the carbolic acid bottle, a 
sufficient amount of local anesthesia is obtained, and a certain degree 
of antiseptic effect is, at the same time, produced. The incision should 
be deep and free, and so made as to cause least scar and the best 
drainage. Where a small incision is desirable, the use of the aspirator 
is to be condemned ; in such a case, a fine drainage-tube thoroughly 
disinfected may be inserted through an incision not much larger than 
the diameter of the tube. The part may be dressed with any of the 
following lotions, applied upon lint and covered with oiled silk : 

1. Carbolic acid, 1 ounce. Water, 39 ounces. 

2. Alcohol, 10 ounces. Water, 30 ounces. 

3. Chloride of zinc, i ounce. Water, 40 ounces. 

4. Corrosive sublimate, 5 grains. Water, 40 ounces. 

5. Permanganate of potash, 20 grains. Water, 40 ounces. 

6. Boric acid, 2 ounces. Water 40 ounces. 

7. Boroglyceride, 3 ounces. Water, 37 ounces. 

8. Tincture of iodine, 2 drachms. Water, 39 ounces. 

If any fetor exists, the cavity of the abscess may be freely washed 
out with the above solutions, and if unusually extensive, 50 per cent, 
of water may be added. For small suppurating cysts and abscesses in 
connection with diseased bone, solutions of double the above strengths 
may be used, or the cavity may be swabbed with lint soaked in solu- 
tion of chloride of zinc, 1:10, pure carbolic acid, or iodized phenol 
(iodine, 1 ounce ; carbolic acid, 4 ounces), and afterward washed out 
thoroughly with any of the above solutions. 

A good plan is to apply a poultice of linseed meal, thickly sprinkled 
over with boric acid, immediately after the evacuation of the pus. A 
pad of salicylic, boric, or iodoform wool soaked in warm water may be 
applied. Abscesses in the neighborhood of sources of putrefaction, as 
about the anus, should be opened at some distance from the dangerous 
region, even though it should not be the most dependent spot. An 
incision should be made through the healthy skin a few inches distant, 
and a canal tunnelled to the sac of the abscess. 

For chronic abscess (psoas, etc.), strict antiseptic precautions should 
be observed, free drainage by a tube, and, if necessary, counter open- 
ings should be made. (See Psoas Abscess.) In opening deep abscesses, 
especially in the region of large and important vessels, as in the neck 
and axilla, Hilton's method should be employed : An incision being 
made through the skin by a scalpel, the blades of a pair of dressing 
forceps are inserted deeply and then opened forcibly, so as to tear 
through the deeper tissues until pus is reached, after which a drainage- 
tube is inserted, and the wound dressed as before described. 

For abscesses of ordinary size the writer has found the best routine 
treatment to be a large pad of well-teased carbolic tow laid over the 
wound, and secured by a slack bandage, and in cases where expense is 
to be considered, a similar pad of oakum will be found a splendid 
dressing. One dressing in twenty-four hours, even in profuse suppura- 



14 ABSCESS. 

tion, will generally be sufficient, as the pad can be made sufficiently 
large to soak up a large quantity of pus. A few shreds of the tow or 
oakum may be pushed into the cavity, and left projecting from the 
wound; in this way all the advantages of a drainage-tube may be 
obtained, and the lips of the incision are at the same time prevented 
from healing, and the sac allowed to granulate from the bottom. Where 
the abscess continues to discharge, the compound tincture of benzoin 
has been injected by the writer with great success. It often causes 
rapid healing, and is a powerful antiseptic, and produces little irritation 
or pain. 

To treat acute and chronic abscesses by the strictly antiseptic method, 
an incision is made under the spray of carbolic lotion (1 : 20) by a 
scalpel purified in a similar carbolic solution, and after pressing out 
the contents of the sac, its walls may be well scraped with a sharp 
spoon and a purified drainage-tube inserted, and whilst the spray is 
still being played upon the part a large pad of carbolic gauze is laid 
over the wound without the intervention of the usual protective of oiled 
silk and copal varnish, and the whole covered with gauze dipped in 
carbolic lotion (1 : 30) and bandaged. , Each change of the dressing 
should take place under the spray, and when there are any special 
reasons the carbolic gauze and lotion may be replaced by boric gauze 
and lotion, and should the skin become irritated, boric ointment (1 : 8) 
may be smeared over it under the gauze. 

The tendency of modern surgery in the treatment of abscess is moving 
in another direction, and though the writer has no experience of the 
methods, the reports are so satisfactory that they will probably become 
recognized surgical procedures. 

In America, Wile has successfully treated more than 100 abscesses 
in the following way — the method is practically the same whether the 
abscess be acute or chronic : — He inserts a large-sized aspirator needle 
into the sac, and to this he attaches a special little pump, and removes 
all of the contents possible. The sac is then filled quite full (mod- 
erately distended) with equal parts of water and a 20 per cent, solution 
of peroxide of hydrogen through the needle without removing it. 
Immediately the cavity becomes distended, and the accumulated gas 
and solution rush through the needle, carrying much debris with them. 
The pump is again applied, and everything removable pumped out. 
More solutionis then injected and removed, till a perfectly clean cavity 
is obtained. A solution of corrosive sublimate (1 : 2500) is then in- 
jected and withdrawn two or three times, till a perfectly aseptic cavity 
is obtained. The needle is then removed, and over the site of the 
abscess a large pad of iodoform gauze is fastened by a bichloride of 
mercury gauze bandage, which is left in situ for from four to ten 
days, after which time he reports that he always finds complete closure 
of the cavity, perfect adhesion of its walls, and not a trace of the 
abscess left. 

He reports that the patients are delighted that no knife is used, and 



ACIDITY. 15 

but very little pain produced. No after-dressing are required. No 
salves, solutions, and daily washings or dressings are needed for this 
simple, almost painless procedure, which causes a rapid cure and no 
cicatrix. The method is not applicable to multiple abscesses, or those 
situated in any of the great cavities of the body. 

Bilroth opens tubercular abscesses freely, scrapes out all that can be 
removed, fills the cavity with 10 per cent, iodoform emulsion, and sews 
them up tightly again, with excellent results. 

Brims treats all tuberculous and joint abscesses in a similar manner. 
He aspirates thoroughly by inserting a needle into the sac or joint, and 
injects a sterilized 10 per cent, emulsion of iodoform in glycerin or 
olive oil. Into large joints he injects 2 to 6 c.c. at one or various 
points. All cold abscesses, spinal abscesses, and every joint abscess, as 
well as tubercular empyema, may be treated in this way. 

Trendelenburg applies this plan to the treatment of all forms of 
local tuberculosis of soft parts, as of glands, testes, and lungs. 

Verneuil treats all chronic or cold abscesses by aspiration and the 
injection of antiseptic solutions as just mentioned, his favorite agent 
being iodoform dissolved in ether. 

Piechaud applies the same method to all acute abscesses, even if the 
skin over them be thinned and undermined. He aspirated by the 
ordinary aspirator, and then injects a solution of 1 : 1000 of bichloride 
of mercury, and reports that uniform success follows the plan. 

It is obvious that of these methods there may be endless modifica- 
tions to suit individual cases, and the plan of Wile is the most thorough, 
and gives the speediest results. 

The injection, as carried out by Bruns, for tubercular abscess will 
require repetition every fourteen days, and sometimes oftener. 

ACIDITY. 

The distressing sensation following the regurgitation of acid liquid 
from the stomach in dyspepsia and other gastric affections is but a 
symptom of these affections, and its treatment should only be discussed 
as part of their therapeutics. It is, however, briefly referred to here 
for convenience and facility of reference. 

It has been assumed that the very painful acidity coming on after 
a meal during the period of gastric digestion is caused by an increase 
in the amount of gastric juice secreted. The burning liquid which sets 
the teeth on edge and feels like vitriol as it regurgitates into the mouth 
is a mixture of butyric and lactic acids, often with some acetic. It is 
the product of decomposition, arising from fermentation in the sugar, 
starch, or fats swallowed, and, in most instances, it arises from delayed 
digestion caused by a deficient supply of gastric juice. It is, conse- 
quently, intensified by those remedies which diminish the amount of the 
digestive fluid. 

The physician is often called upon, in an acute attack, to relieve the 
severe pain produced by the irritation of the acid. To give acids under 



16 ACIDITY. 

such circumstances is worse than useless. One large dose of an alkali 
gives immediate relief. The amount should be sufficient to neutralize 
the large and often enormous quantity of highly irritating, acrid acid 
present. Fermentation is at once arrested. 2 drachms of bicarbonate 
of soda or potash may be required, and the writer has given more than 
double this amount. If this should fail to give relief, an emetic must 
be administered. 

These remedies, it is to be understood, are not to be often or habitually 
employed, or serious troubles may, result ; but when used they may be 
given unsparingly. Often at the beginning of what would become a 
painful attack, one large dose of lactopeptine, 30 to 45 grains, will dispel 
all uneasy sensation, and there is no objection to such treatment being 
frequently employed. Papain is more valuable, as it may be given 
with full doses of alkalies, whilst pepsin will only digest with acids. 
In very chronic cases, and especially where the fermentation is de- 
pendent upon some organic lesion, such as obstruction at the pylorus, 
all treatment fails, because the stomach still retains some ferment when 
the fresh food is swallowed, and thus the process is kept incessantly 
going on. In such cases, very satisfactory results will be obtained by 
washing out the stomach thoroughly with a weak solution of boric acid 
or Condy's fluid. The writer has seen pain and acid vomiting disap- 
pear, never to return, after having withstood everything prior to this 
treatment. Having relieved urgent symptoms, remedies may be com- 
menced which retard or prevent fermentation changes, and formost 
amongst these is creasote, which is now easily procured in soft gelatin 
capsules, each containing one minim. Six may be given in the day ; 2, 
one or two hours after each meal. 

Carbolic acid, 1 to 3 minims, may be likewise used. Sulphurous 
acid, in doses of 1 drachm, freely diluted ; sulphocarbolates of soda and 
potash, sulphites of the same bases, or salicylates, in 10 to 20 grain 
doses, may be given, or oxide or nitrate of silver in doses of i grain in 
pill. Often the writer has obtained benefit from 5 minim doses of 
oils of cloves and peppermint, which are powerful and harmless anti- 
septics. 

Charcoal freshly dried and given in the dry state, wrapped up in 
wafer paper, is a powerful absorbent of the gas which accumulates 
during the acid fermentation, and which adds to the distress of the 
patient. 

Having relieved the more acute stages, the physician should direct 
attention to the condition of the gastric mucous membrane, which is 
the source of the trouble. Subcarbonate of bismuth, 10 grains ; heavy 
magnesia, 10 grains ; and morphia, ^ grain in powder, will afford the 
best routine treatment. An excellent combination is : 

& . — Bismuth subnit. gr. xv. 

Lactopeptin. ........ gr. xv. 

Pulv. ipecac, et opii gr. ij. — M. 

S. — Make twenty such powders. One to be taken three times a day. 



ACNE. 17 

Or, 

R . — Magnes. carb. pond. ...... gr. x. 

Papain (Finkler) . . . . . . . gr. ij. 

Pulv. opii gr. }. — M. 

S. — Make twenty of such powders. Take one three times a day after meals. 

These may be given midway between meals. It is a great mistake 
in these cases to give opium in such doses as might affect the cerebrum. 
-\ grain of opium will be found a maximum dose for the purpose — i.e., to 
act as a local sedative. Often y 1 ^ grain will be found sufficient. After 
a time tonics — the vegetable bitters in combination with mineral acids 
— may be judiciously administered. 

It is of the utmost importance to regulate the diet, and everything 
found by the patient to increase the acidity should be carefully avoided. 
Pastry and fermented liquids are especially hurtful. English beer 
should be forbidden, though Pilsner and lager beer may be freely 
taken. Wines of all kinds should be used with great caution. 
Starchy and saccharine foods should be given with care, but meat, 
fish, and poultry may be allowed. Skimmed milk and kali water, or 
lime water, may constitute the entire diet till the stomach returns to 
its normal condition. 

ACNE. 

The treatment must be constitutional and local. Disorders of diges- 
tion, sexual excitement, and menstrual disturbance should be corrected 
by appropriate remedies. The presence of a large amount of sugar 
in the diet, and the free use of beer, wines, and all fermented liquors 
is to be forbidden. 

Bismuth, in large doses, is the best of all remedies if there be any 
gastric irritability ; and very full doses of bromides in sexual disturb- 
ances. 

In most cases it will be advisable to give a series of mild mercurial 
purges at the beginning of the treatment. These may be occasionally 
repeated at intervals. One large dose of cod liver oil at bedtime to 
act as a laxative, especially in thin subjects, is of great value. The 
best results, in robust patients, are obtained by frequent purgation by 
any active mineral water or saline cathartic. 

Payne speaks highly of the following mixture. It may be given in 
ansemic cases with much advantage : 

R . — Ferri sulph gr. xxiv. 

Acid, sulph. dil. . . . . . . . gj. 

Magnes. sulph. . . . . . . . giv. 

Sodii sulph. . . . . . . . . 3 iv. 

Aquae menthse pip. ...... ad ^xij. — M. 

S. — Take two tablespoonfuls before meals two or three times a day. 



18 ACNE. 

Sulphur and arsenic internally — 10-20 grains of sulphur mixed 
with a teaspoonful of Keiller's orange marmalade (precipitated sul- 
phur may be substituted), and the dose administered three times daily 
produces often good results ; y 1 ^ grain of sulphide of calcium, in a 
pill, acts in a similar manner. These remedies are often of very great 
value in simple acne indurata. 

In very chronic cases arsenic may be tried, but this remedy must be 
continued for a considerable period before good results are obtained. 
The dose need never exceed three minims of arsenious acid solution, 
and should be given four times daily along with meals. It is advisable 
to give arsenic for five or six weeks, and then stop and- begin the in- 
ternal use of sulphur for two or three weeks, and continue thus alter- 
nating for several months ; or, whilst arsenic is being administered, one 
nightly large dose of sulphur (1 drachm) may be given. Belladonna, 
bromide of potassium, ergot, ichthyol, nitrate and oxide of silver, 
phosphorous and many other drugs are recommended. When they do 
good it is only because they have probably relieved the affections which 
are the cause of the disease; they cannot be said to have a specific 
effect upon the sebaceous glands. 

The local treatment of acne might fill a fair-sized volume, each der- 
matologist advocating special formulae of his own. Only those advo- 
cated by the best of authorities need be mentioned, and the following 
is, perhaps, the best routine method : 

In the milder forms of the disease, the inflamed glands, with their 
obstructed ducts, should be submitted to smart friction with a rough 
towel after thorough washing with soap and hot water, or steaming of 
the face over boiling water. Any of the pimples or comedones which 
show black points or evidences of pustulation should be pressed, and 
their contents squeezed out by firm pressure with the fingers ; or, better 
still, by firmly pressing with a watch-key form of instrument devised 
for the purpose. Good results may sometimes be obtained by mowing 
down the summits of the comedones with pumice stone, fine sand, or 
powdered marble, before applying pressure. After this, the following 
lotion should be freely dabbed over the face and allowed to dry : Pre- 
cipitated sulphur, 2 drachms ; precipitated carbonate of zinc, 40 grains ; 
spirit, 1 ounce ; rose water, 9 ounces. The sulphur, according to some 
observers, acts better .if combined with an alkali, and the following 
combination may be regarded as an exceedingly dilute Vleminckx's 
solution : 



R . —Sulphur, prsecip. 
Zinci. carb. prsecip. 
Aquse rosse 
Liquor calcis. 
Eau de Cologne 

S. — Use as directed. Shake well. 



3ij- 

3ss. 

3iij.-M. 



ACNE. 19 

This will be found the most satisfactory method of dealing with mild 
cases of acne of the face, when there is moderate suppuration and little 
pain and redness. If the acne does not soon yield, a lotion consisting 
of corrosive sublimate, 12 grains ; spirit, 1 ounce ; .and almond emul- 
sion, 8 ounces, with glycerin, 1 ounce, may be tried. These lotions 
should be freely applied at least morning and night, and, when possi- 
ble, once or twice daring the day, and allowed to remain on until next 
application of the soap and friction. Oxide of zinc may be substituted 
for the carbonate, but the latter is less noticeable, being nearly the 
color of the skin. 

In those cases where lotions are not convenient, the same objects 
may be secured by rubbing in an ointment like the following : 

Be . — Sulphur, prsecip gr. xxx. 

Zinci carb. prsecip. . . . . . . gr. xxx. 

Lanolin, purif. . . . . . . . 3jj. 

Acid, carbolici TTL- x ^. — M. 



O] 



R . — Hydrag. amnion. ...... gr. xxx. 

Adip. benzoat . . ^j. — M. 



Some cases in the author's hands have yielded to an ointment of 
hypochlorite of sulphur, 1 drachm, and lard, 1 ounce. 

Shoemaker insists upon the puncturing and evacuation of all pus- 
tules by incision with a needle-knife instrument in preference to 
squeezing, and followed afterward by soothing ointments of oleates of 
lead and bismuth, 2 drachms to 1 ounce. 

Where there is much tenderness and redness, with free pustulation, 
the friction must be dispensed with, and soap used very sparingly. An 
over-fatted basis soap like " vinolia " may, however, be freely used in 
all cases of acne. In those case where active inflammatory changes 
are going on, an astringent lotion of strong solution of subacetate of 
lead, 4 drachms; spirit, lj ounces, and rose water, 10 ounces, may be 
freely applied after steaming of the face. 

Where there is much induration present, steaming and friction 
should be followed by mild mercurial ointments, such as diluted citrine 
ointment, or Hebra's solution of green or potash soap in strong spirit, 
may be rubbed in. The following is the formula for Hebra's soap 
solution : Green soap, 4 ounces ; rectified spirit, 2 ounces ; spirit of 
lavender, 1 drachm. Or a mixture of 4 drachms of liquor potassa?, and 
9? ounces of elder flower water, may be applied. 

Hertzmann's method of treating indurated or pustular acne is to 
apply strong chloride of iron solution to each pustule after evacuating 
it; to apply frictions to the face of carbolic lotion 3-5 per cent., and 
afterward the following : 



20 ACNE ROSACEA. 

R. — Acid, salicylic. . . . . . . • SJ- 
Spt. vini rect. (95 per cent.) .... ^viij. — M. 

For the seborrheic form he advises daily frictions of Vleminckx's 
solution (described' in the article on Scabies.) For the papular form 
he recommends frictions with a weak Hebra's soap solution, and in 
very bad cases the following : 



R.— Naphthol. . 
Sulph. prpecip. 
Lanolin. 
Sapo viridis 



3ijss. 



Iodide of sulphur ointment has been used in very chronic cases with 
benefit. The injection of nitric acid, or nitrate of mercury solution, 
into the pustules is a plan that few will ever try. It produces pain, 
often of a very severe kind, and may cause unsightly scars. 

Good results may sometimes be produced by touching the summits 
of the pimples by the plain end of a wooden match dipped in pure 
carbolic acid, or the strongest liquor ferri chlor, only operating upon 
a limited number at once ; the pustules may thus be caused to wither 
up and disappear without leaving a scar. 

The author has had success, after failure with the above list, by 
using the following valuable formula of Unna : Benzoated zinc oint- 
ment, 10 drachms ; rice starch, 5 drachms ; pure resorcin, 30 grains ; 
corrosive sublimate, 3 grains. This should be well rubbed in after 
steaming and w T ashing with vinolia soap three or four times a day. 
See author's Materia Medica, fifth edition, page 94. 

Unna also recommends an ointment consisting of lanoline, lard, 
solution of chloride of calcium, oxygen water, 2£ drachms each, and 
precipitated sulphur, 1 drachm. 

ACNE ROSACEA. 

The name acne applied to this affection should not tempt the student 
to apply the ordinary acne treatment, which is worse than useless. As 
the disease in its early stages is almost always depending upon an irri- 
table condition of the gastric lining membrane, often associated with 
distinct evidence of dyspepsia, the physician should vigorously attack 
this error. If not corrected, the erythematous stage will sooner or later 
pass into one of persistent dermatitis with pustulation, thickening and 
hypertrophy, which can only be relieved by the knife or cautery. The 
treatment should be directed to the cause of the dyspepsia, and if this 
can be discovered to be depending upon the ingestion of irritating 
food, alcoholic beverages, or condiments, such should be at once 
stopped ; irregularities in the time of eating should be avoided, and, 
of all remedies, alkalies are most useful. Bismuth subcarb., 10 grains ; 
magnesia carb., 10 grains ; powered opium, y 1 ^ grain three times daily, 



ACNE ROSACEA. 21 

midway between meals. Or, Gregory's powder, 1 ounce ; powdered 
gentian, 1 ounce ; and bicarbonate of soda, 1 ounce ; mixed and given 
in doses of a large teaspoonful in water after meals. 

Saline purges following a pill consisting of blue mass, 4 grains ; 
euonymin, 2 grains, every third night, are very useful. Abnormal 
irritability of the gastric nerve endings, leading to vasomotor disturb- 
ances in the circulation of the nose and face, is always present, and 
the author finds that the following often gives marked relief: Anti- 
pyrine, 100 grains; liquid extract of coca, 2 ounces; tincture of 
orange, 1 ounce ; glycerin, 1 ounce ; in doses of a teaspoonful between 
meals. 

Two capsules, containing 1 minim of pure creasote each, given before 
meals often remove the dyspeptic troubles, and diminish the congestion 
caused by the reflex inhibition of the vasomotor nerves, but upon the 
whole more satisfactory results will follow the antipyrine and coca 
treatment after the active dyspepsia has been removed. In women 
acne rosacea often arises in the disturbance caused by the cessation of 
the menstrual flow, and here attention should be at once directed to 
the state of the nervous system and undue reflex excitability combated 
with full doses of bromide of sodium, with 2 minim doses of arsenious 
acid solution, or the following : 



R. — Potassii iodidi . 
Potassii bromidi 
Liq. acid, arsenios. 
Tinct. sumbul . 
Camphorse aquae 



. gr. xl. 

• 3J SS - 

• 3ij- 

ad ^xij. — M. 



S. — Take a tablespoonful, three times a day, after meals, with water. 

Local treatment is of little value. In the early stages some relief 
may be obtained by alkaline lotions. Bicarbonate of soda, 1 ounce in 
water 30 ounces, freely applied ; or an ointment of 4 drachms of 
strong solution of subacetate of lead to 2 ounces of lanoline may be 
applied. 

Shoemaker advises an ointment of oleate of bismuth to be applied, 
and the greased surface powdered over with a mixture of oleate of zinc, 
subcarbonate of bismuth, and powdered starch. The ointment of hypo- 
chlorite of sulphur is recommended, but generally it does harm. 

Free scarification by a needle-knife instrument, containing many 
small blades, drawn across the affected part to cause obliteration of 
the hypertrophied vessels, has been followed by good results in the 
hands of some men. Electrolysis carried out by thrusting a fine 
needle, connected with the negative wire from about 6 Leclanche ele- 
ments, deep into the tortuous vessels is practised. The continuous or 
faradic current may be tried, and if there be much hypertrophy, free 
removal must be carried out by the surgeon either with the knife or 
galvano-cautery. 



22 ACROMEGALY— ADDISON'S DISEASE. 

ACROMEGALY. 

No treatment is of the slightest avail in this rare and interesting 
deformity. The enormous growth of the hands and face proceeds 
steadily in the presence of large doses of iodides and the other drugs 
hitherto tried in vain. Erb, after discussing the pathology of the dis- 
ease, concludes by stating that alterative drugs would seem to be indi- 
cated in the early stages, but that tonic treatment will as often be called 
for owing to the initial weakness and nervousness, the drugs being 
selected which seem best to suit the individual case. Ruttle has given • 
great relief to several painful symptoms in a case of this affection by 
using exalgine. 

ACTINOMYCOSIS. 

The now demonstrated fact that this disease is conveyed to man from 
cattle and horses suffering from what is known as " lumpy jaw," at 
once demonstrates the possibility of preventive treatment. Absolute 
cleanliness is all that is required. As soon as the disease appears in 
man, it can only be met by complete removal by surgical methods. 
Caustics and antiseptics are not to be relied upon. Wherever the 
characteristic yellow grains, visible to the naked eye, are found, the 
abscess cavity containing them should be freely incised, and not a trace 
of the affected tissue left. It should be scraped with a curette or de- 
stroyed with the cautery. When the disease attacks the alveolar pro- 
cess of the jaw, this should be removed by the curette, knife, gouge, or 
saw. When it has crept into the interior of the hollow bones of the 
face, these should be opened up by the chisel and gouged out, and after 
the application of a strong caustic, packed firmly with iodoform gauze, 
and permitted to heal up from the bottom. 

The entrance of the fungus through decayed teeth should always be 
looked for in doubtful cases. The sooner its presence is detected the 
more efficacious is treatment. 

Actinomycosis of the lung has been treated by cutting down and 
resecting the lung, but little hope is to be expected from such a serious 
measure. 

Keller diagnosed the disease in the brain in a patient who had 
abscesses over the ribs, w T hich had been opened and scraped. The skull 
was trephined, pus extracted, immediate improvement followed and 
lasted for eight months, when the symptoms returned and death fol- 
lowed a second operation. 

ADDISON'S DISEASE 

gives to the student a striking instance of the uselessness of attempting 
treatment without some knowledge of the pathology of the disease. 
All that he can hope to do in the present state of uncertainty about 
the cause of the affection is to treat symptoms. Anseinia should be 



ALBUMINURIA. 23 

combated by iron and arsenic. Vomiting should be treated with 
gastric sedatives like bismuth, and loss of appetite with tonics. Fagge 
suggested iodine both internally and externally. It appears to the 
author that as in all probability there must be a serious implication 
of the ganglia and branches of the sympathetic interfering with their 
inhibitory function, benefit might be obtained by the assiduous appli- 
cation of a strong, constant current to the region of the supra-renal 
bodies. 

In hospital or private practice he has never seen any benefit from 
any drug which he has used, and chloride of gold, nitrate and oxide 
of silver, arsenic, antipyrine, and many other substances were pre- 
scribed without effect. 

Assiduous and even forced feeding seems to check the progress of 
the disease for a time till the stomach gives up. 

ALBUMINURIA. 

Since this condition will be found in more than 50 per cent, of the 
cases to be dependent upon Bright's disease, its treatment will be men- 
tioned under that head. In those cases where albumin appears in the 
urine, independent of renal disease, it may (speaking generally) be 
said to be in such small amount as not to call for any special treatment. 
Where, however, more than a trace is pretty constantly detected, the 
physician should determine the cause and treat it. If, as is common, 
the albumin appears as the. result of defective assimilation of albu- 
minoids, attention should be at once directed to the state of the 
digestive organs, and especially the liver ; and there is no more potent 
remedy in such cases than a strictly milk diet, with or without pepsin. 
Home-made koumiss, prepared by mixing i pint of water, i pint of 
buttermilk and 4 pints of fresh milk and 1 ounce of loaf-sugar, leaving 
in a warm place and shaking occasionally for thirty-six hours, will 
make a palatable draught, very suitable in many cases of disease, 
especially in Bright's disease. Albuminuria occurring during febrile 
attacks, zymotic diseases, inflammatory affections, etc., will yield to 
the remedies suitable for the primary disorder. When depending upon 
obstruction to the circulation, as in valvular affections or cirrhosis, the 
albumin will disappear upon the removal of the cause when possible. 
Cardiac tonics and diuretics, by strengthening the heart muscle and 
stimulating the renal bloodvessels, may cause its disappearance. The 
wet pack is very serviceable in such cases. 

Arsenic and iron, separately or combined, are of great value in the 
treatment of chronic albuminuria, especially when the drain of albu- 
min has produced a marked effect upon the blood. Iron affords the 
best results in albuminuria, depending upon a morbid state of the 
blood, as in scurvy, pyaemia, and hospital gangrene. The albuminuria 
of adolescence, or so-called intermittent or functional albuminuria, 
generally yields readily to rest in bed and a strict milk diet. It is 



24 ALCOHOLISM. 

hardly necessary to remind the student that albuminuria, depending 
upon discharges finding their way into the urine from the urethra, 
prostate, bladder, or pelvis of the kidney, can only be treated by. 
surgical methods directed to the diseased conditions in these localities. 
As a rule, the broad statement may be accepted as true that no drug 
possesses the specific power of markedly causing diminution in the 
quantity of albumin appearing in the urine, and it is better for the 
physician to attack the cause than to lose time in administering the 
usual list of mineral and vegetable astringents. Moreover, some 
authorities affirm that their use is positively injurious. 

Caffeine, lime-water, copaiba, fuchsin, gallic and tannic acids, glo- 
noine, hydrastis, acetate of lead, ergot, cantharides, alum, chloride of 
gold, chloral, chloride of sodium, turpentine, and a host of other reme- 
dies have each, in somebody's experience, been found to markedly 
diminish the amount of albumin ; but, when tested fairly, have been 
generally found to fail. 

The albuminuria of pregnancy, when slight or transient, does not 
call for medication; when persisting and copious, it may be safely dealt 
w 7 ith as if occurring in Bright's disease, which see. 

ALCOHOLISM. 

In the acute stage of drunkenness, falling short of alcoholic poison- 
ing, the physician may be called upon to administer a remedy to 
counteract rapidly the symptoms of alcohol. The solution of acetate 
of ammonia, in doses of a wineglassful every fifteen minutes, will often 
causes the uproarious or maudlin stage of drunkenness to give place to 
a condition of perfect sobriety in a surprisingly short time ; 1 drachm 
of carbonate of ammonia, dissolved in 2 ounces of vinegar, makes an 
efficient substitute in the absence of the B. P. solution. 

The hypodermic injection of £ to £ grain of pilocarpine will act with 
equal magic, and it can be administered when the patient refuses, or 
even when he is unable, to swallow the bulky, unpleasant solution. 
Cocaine, kola nut, caffeine, and very strong coffee produce somewhat 
similar results, but much more slowly and less satisfactorily. 

If coma has already occurred, the stomach-pump must be used, and 
cold affusion or galvanism resorted to. (See under Poisoning.) 

Acute gastritis following a debauch, and leading to serious vomiting, 
is best met by a large blister over the stomach, and by the adminis- 
tration of small quantities of ice by the mouth, and morphia hypo- 
dermically, or by the following mixture : 

R • — Bismuthi subcarb. . 
Acid hydro-cyan. dil. 



Mucilag. recentis 
Morphise hydrochlor. 
Aquae camphorae 
S. — Take a teaspoonful every hour ; shake well 



• 3 U J- 

• 3j. 

• 3jss. 

• g r - j- 

ad giv.— M. 



ALCOHOLISM. 25 

If there be no collapse or severe pain, the stomach should be washed 
out with 40 ounces of water, in which 5 to 10 minims of creasote have 
been dissolved. In the chronic vomiting creasote capsules, T \ grain of 
morphia in minute pill, or minim doses of arsenious acid solution, or 10 
grains of bismuth and 5 grains of heavy magnesia may be given. The 
writer has often seen vomiting stop after 5 to 10 minim doses of tinc- 
ture of capsicum, which had been given to allay the craving. By far 
the best food at this stage is good buttermilk turned acid, and if very 
acid it can be freely given with kali water, and this combination may 
stop vomiting which has resisted all treatment. The fluid known in 
Ireland as buttermilk differs widely from the vile compound known by 
the same name in most parts of England. 

The chronic dyspepsia of drunkards is a troublesome affection in 
which drugs are of little value. The great difficulty experienced by 
the physician is to select some form of liquid nourishment which can 
be taken copiously by the patient at short intervals, which will be 
easily digested and acceptable to the vitiated palate. There is nothing 
better than the buttermilk just mentioned, which may be given in 
unlimited amount. It may be administered every fifteen or thirty 
minutes, either alone or mixed in equal quantity with fresh milk, soda, 
or kali water. The formula mentioned upon page 23 for preparing 
artificial koumiss will be found a palatable and nutritious liquid. 
Where buttermilk is not obtainable the koumiss prepared with yeast 
and cow's milk may be employed. (See fifth edition of author's 
Materia Medica, page 578). Carefully prepared beef-tea and chicken 
soup, either of which can be thickened with barley water, and fortified 
with Liebig's extract of meat, or ordinary clear or thick soup of any 
kind that the patient may fancy can be freely given. If there be great 
weakness or prostration, and the stomach refuses to accept any nourish- 
ment, except in very small quantity, Valentine's beef juice in drachm 
doses every half hour, or Brand's beef jelly with ice every hour, affords 
the best chance of tiking over the difficulty. Associated with the 
gastric symptoms is the intense craving for alcohol in some form. This 
should be stoutly withheld. The physician generally sees the patient 
after he has been indulging freely for a considerable period, and alarm 
has been excited by the depression produced by continuous vomiting 
or by the dread of delirium tremens. The serious difficulty which at 
once confronts the attendant is the responsibility of cutting off the 
stimulant. There is a deeply rooted prejudice against this line of 
action held both by the unfortunate victim and his friends, and if such 
a step be taken, any mishap occurring is sure to be attributed to this 
point in the treatment. 

In the vast majority of cases this is the correct course to pursue. 
The experience of gaol surgeons proves how constantly immediate im- 
provement sets in, and how exceedingly rarely does any mischief follow 
the abrupt withdrawal of stimulants, even in the broken down patients 



26 ALCOHOLISM. 

committed to prison for some act perpetrated during their prolonged 
debauch. 

This prejudice has, to a large extent, arisen from the aversion to 
alcohol often noticed in patients just before symptoms of delirium 
tremens set in at the end of a drinking bout. The supervention of 
the delirium is attributed to the cessation of stimulation, whilst in 
reality, it is but a symptom of the disease. The prejudice is also trace- 
able to the memory of the horror and depression caused by the cutting 
off of the stimulant in former attacks, and the patient is generally loud 
in his protestations that death will follow the sudden withdrawal of his 
liquor. 

Though the physician should act firmly in insisting upon this com- 
plete withdrawal, he will be wise to postpone it for a short time if he 
has good reason to suspect that symptoms of delirium tremens are about 
to immediately declare themselves. 

Exception should be made in those very much debilitated from dis- 
ease, especially in those suffering from heart affections, and in the aged. 
If the pulse should exhibit marked signs of weakness and irregularity ; 
if there has been prolonged insomnia ; or if the history of the patient 
shows clearly that he has for years been taking alcohol in moderate 
doses daily before his recent excess, then small regulated doses of alco- 
hol should be administed to him at stated intervals, the dose to be pro- 
portional to his habits. Generally speaking, 12 ounces of whiskey 
should be rarely permitted during the twenty-four hours, and 6 ounces 
for all cases may be said to be a fair allowance during the first few 
days, though the patient may have been in the habit of taking much 
larger quantities. 

If there is much gastric irritability champagne may be given, but all 
other wines should be forbidden. Good whiskey alone being selected 
as the stimulant, the rule should be laid down that it must be taken 
by the patient mixed with his soup or milk by a reliable nurse. 

In the great majority of instances, the physician when called to treat 
a case of chronic alcoholic poisoning will be safe in fearlessly acting as 
he would in any other case of poisoning — by immediately preventing 
the administration of the poison. Much can then be done with the 
assistance of a firm nurse, who should administer liquid nourishment 
every fifteen or thirty minutes. 

The following may be given with benefit to allay the craving for 
alcohol, and to some extent take its place: 

R. — Spt. amnion, aromat Jij. 

Tinct. cinchona 3 ....... ^ijss. 

Tinct. capsici ^iij. — M. 

S. — A large teaspoonful in half a tumblerful of effervescing potash water 
every hour. 



ALCOHOLISM. 27 

Or the following may be tried : 

R .— Ext. coca> fid gij. 

Tinct. card, conip ^ij. 

Tinct. cinnamom ^j. — M. 

S. — Take a teaspoonful every hour with water. 

Or the following : 

R.— Tinct. jaborandi (1 in 4) £v. 

Tinct. chiratse ^ij. 

Aquse .ad |xx. — M. 

8. — Take a dessertspoonful every fifteen minutes. 

Attention has recently been directed to the value of strychnine and 
nux vomica in the treatment of alcoholism and delirium tremens. The 
author first pointed out in 1882 the striking effects of alcohol in strych- 
nine poisoning, and published a case where recovery followed after the 
failure of the recognized remedies. He is satisfied that in strychnine 
we have a remedy of great value to act as an antagonist to alcohol, 
and he finds that the following will produce good results in diminish- 
ing the craving for alcohol and preventing the depression following its 
withdrawal : 

R. — Tinct. nuc. vomica? . . . . . . . ^ij. 

Aquas camphoree ^ x ij- — M. 

S. — Take a tablespoonful every hour. 

Coca leaves and quassia chips may be chewed during the intervals 
between food and medicine. 

After the relief of the more acute symptoms, tonics, as quinine with 
a mineral acid, and gentian and calumba, may be given. If the gastric 
symptoms continue after the disappearance of the craving, bismuth or 
oxide of zinc, with a minute dose of morphine, -^V grain, may be given ; 
or potas. bicarb., 1 ounce ; acid, hydrocyan. dil. 1 drachm ; aquae to 12 
ounces — a tablespoonful, with an equal quantity of fresh lemon-juice, 
every two hours. 

For the persistent loss of appetite and want of energy, associated 
with restlessness and disturbed sleep, sometimes with traces of halluci- 
nations following long after prolonged alcoholic excess, there is no 
better remedy than the following : 

R . — Quininse sulphatis gr. xxv. 

Acid, nitrohyd. dil gvj. 

Ext. cinchonse liq. giij. 

Aquae destillatse . . . . . ad ^ x. — M. 

S. — Take a tablespoonful three times a day with water before meals. 



28 AMAUROSIS. 

For the insomnia of chronic alcoholism, opium should be sparingly 
employed. 1 grain of the watery extract at bedtime may be given 
occasionally, but bromides may be freely and continuously employed, 
and 10 to 30 grains may be given in conjunction with any of the above 
combinations. It is a good plan to give the bromide of potassium in 
doses, say of 20 grains every three or four hours, alternating with the 
sal volatile and capsicum mixture. Chloral should never be trusted, 
owing to its dangerous depressing action upon the heart. (For the 
treatment of insomnia in delirium tremens see under Delirium Tremens 
and Insomnia.) Long after alcoholic excess has terminated in the 
condition requiring the treatment mentioned in the previous pages, 
the patient should be seriously cautioned, and, if necessary, placed 
under mild restraint, and if the craving continues, and the will be 
unable to resist it, restraint should be insisted upon, and a residence 
in a good inebriate asylum be strongly advised for as long a period as 
possible. 

The treatment of the various diseases and conditions following upon 
chronic alcoholism may be found under Cirrhosis, Delirium Tremens, 
etc. 

AMAUROSIS. 

Accepting this term as only including those cases of total blindness, 
associated with atrophy of the optic nerve without any evidence of 
disease or change in the media or coverings of the globe, it will be 
apparent that but little can be achieved by treatment. A condition 
depending upon so many widely different causes, all tending to eventu- 
ate in a complete white atrophy of the disc, will require very careful 
discrimination as to the diagnosis of the extract factor at work in each 
case. If complete white atrophy has not already occurred, sometimes 
the physician can do a great deal. 

If those cases of amaurosis following diphtheria and scarlatina, if 
the case is recent, strychnine should be freely given, and as a rule its 
administration by the mouth should not be attempted, but at once the 
hypodermic injection of -^ to -j 1 ^ °f a g ram daily should be persevered 
with for some weeks. There is some hope that this measure may be 
of use even in traumatic cases, and good results are obtained in amau- 
rosis after lead, tobacco, and alcoholic poisoning, where already the 
case has passed out of the category of amblyopia. The strychnine 
treatment may be supplemented by a cautious use of the constant cur- 
rent, not more than 4 Leclanche cells being used, and it is a good rule 
to begin with 2, one pole being placed at the occiput and the other 
over the eyebrows. • If there be evidence of syphilis as a cause, rapid 
mecurialization or large doses of iodide of potassium may be tried, 
though it is doubtful if ever success has followed such treatment. 

In those rare cases where amaurosis has rapidly supervened upon 
the sudden suppression of some long standing discharge, as at the cli- 



AMBLYOPIA. 29 

macteric period and after the removal of bleeding tumors, some hope 
may lie in free purgation, and the introduction of a seton or blister 
over the brow. The administration of arsenic (5 minims of Fowler's 
solution) may be continued at the same time that the hypodermic in- 
jections of strychnine are being given. Chloride of gold and sodium 
(U.S.P.) in pills containing ■£$ grain may be given four times a day, 
and in a few cases good results have been recorded. 

Pilocarpine, J grain hypodermically, has, in a few cases, been fol- 
lowed by benefit, and the same may be said of inhalations of nitrite of 
amyl and large doses of santonin at bedtime. 

AMBLYOPIA. 

Many cases of dimness of vision or defective sight, without marked 
visible changes in any part of the eye, have been proved to be caused 
by tobacco, alcohol, or lead poisoning, and a few have been known to 
owe their origin to the continued administration of large doses of qui- 
nine ; sometimes malarial poisoning has been the cause. 

For tobacco amblyopia, or tobacco amaurosis, as it is more commonly 
called (though the latter term should be confined to those cases where 
there is total blindness, which is rare), the first thing to do in the way 
of treatment is to stop immediately and completely all use of tobacco. 
In the case of young smokers this will often effect a speedy cure, but 
in those where the habit has been long established, and especially 
where there are found some evidences of disc atrophy, the affection 
may prove very difficult to deal with, and even in spite of treatment 
may, in rare instances, pass into permanent amaurosis. In addition to 
abstinence from tobacco and alcohol, everything that improves the 
general health and tone should be advocated. General tonics, espe- 
cially strychnine, in mild cases, and in severe ones the hypodermic 
injection of y 1 ^ grain of this drug under the skin in the region of the 
temple daily. Sulphate of zinc in 5 grain doses may be given inter- 
nally after each meal whilst the strychnine treatment is being carried 
out. Teaspoonful doses of Easton's syrup may be commenced when 
tne hypodermics are stopped, which should be soon after decided im- 
provement sets in. 

A careful administration of the induced current is always advanta- 
geous. When quinine is given it should be in doses not exceeding 1 
to 2 grains, and if the constitutional effects should by chance appear, 
owing to idiosyncrasy, the drug must be discontinued. 

Pilocarpine subcutaneously has given good results in many cases ; 
it may be occasionally administered during a course of strychnine. 
Nitrites have been recommended, but their effects are too transient to 
be of any permanent value. 

Amblyopia, caused by chronic alcoholism, will require to be dealt 
with upon the same lines — the total abstinence from alcohol in every 
form being rigidly insisted upon. Everything that can improve the 



30 AMENORRHEA. 

general health, as changes of food, air, and scene, sea bathing, and 
rest to the eyes are to be recommended, and the judicious administra- 
tion of tonics, chief among which is strychnine, or the employment of 
hypodermic injections of this drug in severe cases. The writer be- 
lieves that, where the affection is of long standing, the best treatment 
is to persist in the internal administration of y 1 ^- grain of the chloride 
of gold and sodium in pill, after a few weeks treatment by strychnine, 
with occasional hypodermics of \ grain pilocarpine. 

Often alcoholic and tobacco habits exist in the same person, and of 
course, where amblyopia supervenes, both habits must be stopped en- 
tirely. Quinine amblyopia may be treated in a similar way, though 
the above remedies are seldom required as the affection of sight rapidly 
disappears after discontinuing the use of the drug. 

Amblyopia caused by lead poisoning will require for its treatment 
similar measures directed to the improvent of the general health. 
Iodides of sodium and potassium, in full doses largely diluted, afford 
the best treatment ; they may be advantageously combined with sul- 
phate of magnesia. It is a good plan to cause gentle purgation with 
the sulphate of magnesia in lemonade made with dilute sulphuric acid, 
while the iodide treatment is kept up constantly. 

Sulphurous baths are also of great use. It is needless to say that 
every caution must be employed against the further introduction of 
the poison into the system, by great personal cleanliness, etc. The 
constant current is often of much benefit. The state of the kidneys 
will require attention, and, if albuminuria be present, the possibility 
of uraemia must be remembered and appropriate treatment at once re- 
sorted to, with the view of causing elimination of the urea and other 
compounds by the skin and bowels. (See under Plumbism.) 

Amblyopia coming on during pregnancy must be carefully watched, 
and if the ordinary treatment by purgation and hot packs does not 
afford relief, as in the case of acute Bright's disease, and should the 
amblyopia be passing into amaurosis, at once premature labor should 
be induced, and free purgation kept up afterward until all visual trou- 
bles pass off, and the swollen and congested disc assumes its normal 
appearance. (See under Bright's Disease.) 

ALOPECIA— See Baldness. 

AMENORRHEA. 

Depends upon so many different causes that a resume of its treat- 
ment will necessarily embrace an extensive list of drugs of widely 
differing actions. 

Emmenagogues may be regarded as remedies which, either by direct 
or indirect means promote the menstrual flow. The flow may be 
diminished or absent through purely constitutional conditions, as 
plethora or anaemia, in which cases the treatment will differ widely — 



AMENORRHEA, 31 

the indirect emmenagogue action of cathartics being indicated in the 
case of plethora and the free administration of ferruginous compounds, 
which act as indirect emmenagogues, in the case of ansemia. While, 
again the flow may be absent or diminished through purely local 
causes, when the action of a direct emmenagogue like ergot will be 
indicated. The action of these so-called direct emmenagogues is little 
understood, and a host of remedies are in use about whose modus 
operandi we know nothing beyond the fact that, in some cases after 
their administration, the retarded, diminished, or absent flux returns 
in natural amount. That these so-called direct emmenagogues have 
any direct stimulating effect upon the lining membrane of the uterus 
is exceedingly doubtful. It is, however, certain that most of them, 
when given in large doses, acts as ecbolics, and cause the expulsion of 
the uterine contents by powerful stimulation of the muscular fibres of 
the organ. 

In those cases where the menstrual flow has never appeared, the 
cause may be found in some malformation or in absence of development 
of the sexual organs. If the latter, the case hardly can be hoped to 
come into the sphere of treatment, while, if menstrual discharge has 
been poured out into the vagina or interior of the uterus and retained 
because of an imperforate hymen, or atresia, or occlusion of the 
cervix, os, or vagina, the case falls under the care of the surgeon. In 
atresia, where owing to absence of a considerable portion of the lower 
part of the vaginal canal there is no hope of tunnelling out a new 
passage, it is better to tap the distended sac per rectum, and leave a 
free opening for the accumulated flow and a constant exit for future 
discharge of the anus. 

Where the occlusion is low down, and there is but a thin layer of 
tissue closing the perineum, the treatment will be the same as if an 
imperforate hymen was the cause of the retention, i. e , a free crucial 
incision. The tarry fluid should be allowed to flow spontaneously, and 
no pressure should be employed, but gently syringing with a weak 
solution of bichloride of mercury (1 :5000) will be advisable. 

If the case be one of merely delayed appearance of the first flow, 
the patient being neither malformed nor showing evidence of absence 
of uterus or ovaries, the physician should hesitate before yielding to 
the anxious solicitations of friends to begin active treatment by power- 
ful emmenagogue remedies, always remembering that the menstruation 
may be delayed long beyond the average age without any harm what- 
ever to the patient. It is, moreover, especially necessary to abstain 
from such treatment where there is evidence that the general growth 
and development of the body is below the ordinary standard for the 
age of the patient ; or where the amenorrhoea is depending upon 
phthisis or Bright's disease. If the patient appears in every other 
respect in perfect health, it would be wiser for the physician to refrain 
from the use of drugs entirely, and recommend change of air and 
scene, and active outdoor exercise. 



32 AMENORRHEA. 

Should, however, anaemia or plethora or any other diseased condi- 
tion, or any departure from health be noticeable, it should be at once 
attended to, after which the physician may wait before employing any 
remedy intended to act as a direct stimulant to the uterus until there 
is some indication of an attempt upon the part of nature to establish 
the menstrual flow. This may be recognized by some of the usual 
symptoms preceding menstruation, such as headache and flushing of 
the face, with bleeding from the nose, sense of fulness in the breasts, 
backache, and general malaise coming on periodically. These symp- 
toms cannot long continue in the absence of the menstrual discharge 
without risk to the patient's health. 

The hot hip or sitz bath (about 103° F.) should be resorted to, the 
patient put to bed and covered with warm clothing. Often a good 
hot foot-bath in mustard and water along with hot fomentations to the 
loins answers well, or a large hot linseed meal poultice, with mustard, 
applied to the lumbar region for a few hours every evening may estab- 
lish the flow. It is an excellent plan to give a local hot mustard pack 
by wringing a small blanket out of hot water and mustard, and en- 
veloping in it the lower half of the body and legs, and putting the 
patient to bed. This treatment may be continued once a day for three 
or four days at a time, and it will be well to supplement it by giving 
about 1 ounce of gin or whiskey with a teaspoonful of tincture of saf- 
fron, or 10 minims of oil of pennyroyal or peppermint, with hot water. 
Kue and savine are drugs of great power and should seldom be given. 
The oil of parsley, in capsules containing 5 minims, is not open to the 
objection of causing irrigation like rue and savin. 

Pilocarpine given hypodermically in doses of about i grain, while 
the patient is in the pack, will be found, in the writer's opinion, to be 
the most effectual remedy for causing the menstrual discharge to 
appear. 

If the molimen is ushered in with hot skin and fever, small doses 
of aconite or cimicifuga given every hour (i minim of tincture of 
aconite or 3 minims of tincture of cimicifuga) will afford relief. Can- 
tharides has been employed, # but its administration is followed by 
danger. 

In those cases where the symjrtoms of menstruation are absent or 
only vaguely marked — in other words, where there is no indication of 
a molimen, and menstruation is delayed for a long period after its first 
appearance is naturally expected, unless the patient is really plethoric, 
it will be a wise routine practice to saturate the system with iron. 
The number of preparations at the hands of the physician for this 
purpose is almost endless, but the best is the pill made of the sulphate 
of iron and carbonate of potash, and extensively known as Blaud's 
pill, of which 2 or 3 should be given three or four times a day, after 
meals. Next in value is the preparation known as dialyzed iron, of 
which 30 minims may be given four times a day. Griffith's mixture, 
or a combination of 15 minims of the tincture of iron, and 2 minims 



AMENORRHEA. 33 

of Fowler's solution, is often of great value; as is also Basham's 
mixture. 

If constipation be present, the decoction of aloes may be given with 
an iron preparation, or the pill of aloes and iron or aloes and myrrh 
may be employed, to which asafcetida may be added with advantage. 
The practice of giving strong purgatives, like colocynth and gamboge, 
is to be discountenanced. 

Even in the presence of distinct plethora, a mixture containing 3 
grains of sulphate of iron and 2 drachms of sulphate of magnesia in 
each dose, given every four or six hours, often establishes the appear- 
ance of the flow, the first discharge appearing after free purgation. 

In the class of cases just considered, i. e., where menstruation has 
never appeared, and where no molimen is evident, and where the 
patient's health is apparently good, and there is no dwarfing of body 
or malformation of sexual organs, there is no remedy to be compared 
with the constant current. Beginning with ten Leclanche cells with 
the negative pole on the sacrum, and a large, flat positive electrode 
upon the front of the abdomen taking in both ovarian regions, the 
current may be increased to thirty cells ultimately, though twenty will 
be found enough for ordinary purposes w 7 hen administered for fifteen 
minutes daily. The portable constant current batteries are a source 
of bitter disappointment and annoyance, and the writer advises every 
physician to have a battery of large Leclanche cells permanently fixed 
up in his study, or in any convenient place from which wires can be 
easily brought to a switch-board upon his writing table. The quart 
size (new agglomorate pattern), made by the Silvertown Electric Ap- 
pliance Co., is by far the cheapest and best. In it the porous pot is 
dispensed with, and its slow T and continuous action lasts for two or 
three years or more, and it can be always relied upon when required, 
and easily recharged at trivial cost by any handy servant. 

The faradic current is also valuable, one pole being placed over the 
sacrum, and the other alternately over each ovarian region. It will 
seldom be found necessary to introduce a rheophore up to the cervix 
or fundus, as in Apostoli's treatment, nor will it be found advisable to 
ntroduce a galvanic stem intra-uterine pessary. 

In amenorrhcea occurring in patients in whom the menstrual flow 
had been established for a considerable period, the same general prin- 
ciples of treatment may be kept in mind. It will be the duty of the 
physician to most carefully look into the cause of the suppression, and 
find out the error in health which is at work in suppressing or dimin- 
ishiug the flow, always keeping before his mind the possibility of preg- 
nancy as a cause. 

In the majority of cases a certain amount of anaemia or chlorosis is 
present, and iron will be our sovereign remedy. Its best and most 
constant effects are seen in those bloodless patients where the flow, 
though never for long absent, is nevertheless reduced to a mere trace 
each monthly illness. 6 or 8, or even 12, of Blaud's pills in the 



34 AMENORRHEA. 

twenty-four hours, will often effect a cure both of the anaemia and of 
the obstinate constipation associated with it. The following is a useful 
combination : 

&. — Liq. ferri dialys jfij. 

Glycerin, purif. ....... ^jss. 

Ext. cascarse liq. ....... 3 iy. — M. 

S. — Take a teaspoonful, with water, three times a day, after meals. 

Or 10 grains of the ammonio-citrate of iron in 4 drachms of cinnamon 
water. It is always well before beginning a course of iron, to order a 
few morning purges of Rochelle salt, 6 drachms ; or Epsom salt, 3 
drachms. 

If there be much loss of appetite, with headache and furred tongue, 
a plain bitter with an acid should first be given, as: 

R . — Acid, nitrohyd. dil. . . . . . 3 iv. 

Tinct. nuc. yom. 3 ij. 

Inf. gentianas . . . ' . . . . i§ v \j- — M- 

S. — Take a tablespoonful, with water, three tinier a day, before meals. 

The diet should be carefully looked into, and only the plainest food 
permitted, and, as a rule, stimulants prohibited. The clothing should 
be warm, and woolen stockings, with thick soled boots, should be worn, 
and active outdoor exercise must be insisted upon. 

If in spite of such general treatment the menstrual discharge fails 
to appear at the proper time, the treatment by hot baths and mustard 
packs is to be commenced at about the time when the absent or habitu- 
ally scanty flow is expected, and failing the success of these remedies, 
the so-called emmenagogue drugs are indicated. 

Speaking of cases of amenorrhoea with mental depression and from 
mental shock, G. E. Herman points out that there is no treatment 
from which the reestablishment of menstruation can be predicted. 
Change, fresh air, exercise, food, and tonics are the great therapeutic 
agents. Of these, change is the essential. 

The following drugs are in rupute as emmenagogues : 

Ergot will be found a most disappointing drug generally, but suc- 
cess sometimes follows after a few weeks' trial of a pill, three times a 
day, consisting of 1 grain of ergotine (Bonjean's), 3 grains of ferri 
reduct., 1 grain of aloes socot. Perhaps the best way to try the value 
of ergot is to give two or three large doses, and if no results follow it 
may be given up. 

Rue or Savine in 3 minim doses of the essential oils two or three 
times a day about the expected period have been recommended ; they 
sometimes cause great irritation and pelvic disturbances. 

Santonin in doses of 5 to 10 grains given at bed-time for two or 
three nights has been highly recommended. It often fails, and it 
should be remembered that it is a dangerous weapon, death sometimes 



AMENORRHEA. 35 

following full doses of the drug. It is safer when given along w T ith 
castor oil. 

Quinine iu 10 to 15 grain doses may be tried for a few nights. Any 
benefit to be expected from it will probably appear after one or two 
doses. 

Hellebore has been given in large doses, but it is not to be recom- 
mended. In cases where the flow has been suddenly suppressed small 
doses of the tincture of green hellebore, 1 minim every hour, will act 
sometimes after six or eight doses in strong plethoric subjects. 

Aconite Tincture employed in the same way, also gives good 
results occasionally, and the tincture of cimicifuga in 4 minim doses 
may be similarly used. 

Apiol in capsules, containing 3 to 5 minims, is often serviceable, and 
is not likely to do any harm. 

Permanganate of Potassium. — Much has been written in praise 
of this remedy, and although very strong statements have been made 
about its constancy and value it will be found to very often fail utterly. 
Ringer and Murrell extol it in both anaemic and plethoric cases where 
the flux is delayed or scanty, or suddenly suppressed. 1 to 2 grains 
should be given in a pill thrice daily till catemenia appear, when its 
administration should be discontinued till within four days of the next 
expected period. 

Peroxide of Manganese in similar doses appears occasionally to 
hit. The lactate also, in 2 grain doses, is sometimes successful, as are 
other manganese salts. 

Cantharides is a powerful emmenagogue, and though its dangerous 
and painful effects upon the bladder and kidneys are constantly known 
to follow even moderate doses, it still is used occasionally as a remedy 
to promote the menstrual flow. The dose should commence with i of 
a minim of the tincture in well diluted mixture three times a day, and 
be increased to 2 or three minims cautiously. The writer has, however, 
never used it, and probably never shall use it for this purpose. 

Pennyroyal (mentha pulegium) is a favorite domestic emmena- 
gogue which, in doses of 10 to 15 minims of tho essential oil, often acts 
as a diffusible stimulant possessing some power as a special stimulant 
to the uterus and ovaries, and it is safe and agreeable when dropped 
upon sugar or given in weak hot punch at the time of the expected 
flow. It may be combined to advantage with other drugs of the same 
class, and may be given internally just before injecting pilocarpine. 

Guaiacum is a valuable emmenagogue in young women where the 
menstrual discharge fails to return after rheumatism or rheumatic 
fever. 10 grains may be given in fine powder mixed with marmalade 
or in sherry. The ammoniated tincture may be given with the tincture 
of aloes in 20 minim doses. 

Iodide of Potassium in full doses, 10 to 25 grains, occasionally 
succeeds in restoring the catamenia when other remedies have been 
given up. 



36 ANAEMIA. 

Jaborandi is a remedy which the writer has observed to cause 
hemorrhage from the uterus when given hypodermically (as i of a 
grain of pilocarpine) for other affections, and good results follow this 
treatment in amenorrhoea where the flow stops without apparent cause. 
Benefit may probably be obtained from the internal use of the tincture 
of jaborandi in similar cases, but certainly the best results are to be 
expected from the full hypodermic dose (J to J of a grain) of the alka- 
loid. The dangerous- depression which sometimes follows large doses 
appears, in the writer's experience, to be reduced to a minimum if given, 
when the patient is in a hot sitz bath or local mustard pack. 

Electricity, though somewhat uncertain in its action, is a valuable 
emmenagogue in cases where the menstrual flow has suddenly stopped 
or failed to appear. It is used in these cases in the same way as in 
those where menstruation has never been established. The judicious 
application of the continuous current may be tried alone or in conjunc- 
tion with any of the treatments already mentioned. 

Faradism may be also tried before giving up electricity, when the 
continuous current fails. 

Massage will be found a valuable accessory to the ordinary emmena- 
gogue remedies. The practice of uterine massage, as carried out by 
some operator is not here meant. This is a very questionable proceed- 
ing in most cases, and would seem to be seldom or ever justifiable as a 
remedy in simple amenorrhoea. Massage of the abdominal walls alone, 
or in conjunction with electricity or any other treatment, is clearly a 
legitimate practice. 

Pulsatilla, Aletris Farinosa, Bogbean (menyanthes trifol.), 
Sanguinaria, Hydropiper, Cypripedium, Caulophyllin, and a 
host of American vegetable drugs are loudly praised by those who, 
having given them in amenorrhoea and observed the flow to return, 
have been satisfied about their value. 

AMYLOID DISEASE— See Liver, Diseases of, and Bright's 
Disease. 

ANJEMIA. 

Like amenorrhoea just considered, this condition is but a symptom 
of many different diseases, and its treatment will necessarily imply a 
knowledge of the treatment of various diseases like albuminuria, syph- 
ilis, leucorrhoea, plumbism, hemorrhoids, malaria, epistaxis, phthisis, 
gastritis, etc. 

The first object should be to stop the drain upon the system, whether 
this drain be blood lost by hemorrhage of any kind or by excessive 
discharge of albuminous secretions ; afterward the application of the 
ordinary laws of health — good, easily assimilated food, open-air exer- 
cise, etc. — will be all that is required. 

In acute anaemia, where the patient is sinking from the loss of 
large quantities of blood, the operation of transfusion may be impera- 



ANEMIA. 37 

tive. This may be done in various ways. It is essential to avoid the 
injection of the blood animals into human veins, and to always use 
healthy human blood. There is a strong feeling growing up against 
the transfusion of even human blood. When possible the human blood 
should be defibrinated by collecting in a glass vessel as it flows from 
the basilic or great saphenous vein, and, after whipping with a glass 
rod till the fibrin has entirely been removed, it may be injected through 
a warmed syringe into either an artery or vein. The best artery is the 
radial, and the nozzle of the syringe may be inserted into the opening 
in the vessel either in the direction of the hand or toward the heart. 

If a vein be selected — the basilic being preferable — the blood should 
be injected in the direction of the venous stream, i. e., toward the heart. 

If time does not admit of defibrinated blood being used, the trans- 
fusion must take place direct, notwithstanding the risk of embolism. 
A suitable transfusion apparatus can be easily made out of Dieulafoy's 
aspirator, by having a duplicate of the fittings and rubber tube which 
is to bear the needle at one end and be attached to the end of the 
cylinder at the other. So equipped the aspirator will bear, attached to 
each projection at the end of the cylinder, an India-rubber tube with 
a suitable mounting at its extremity for the insertion of any of the 
hollow needles or canulae. Such an apparatus is always at hand, and 
the modification in no way interferes with its action as an aspirator and 
it is always ready at a second's notice, whilst the various forms of trans- 
fusion apparatus being so seldom used are sure to be out of order when 
required. 

One needle being inserted into the basilic vein of the patient, the 
other is inserted into the basilic of the donor. It is certainly desirable 
that the aspirator and tubes and needles be filled with warm, normal 
saline solution (0.6 per cent, chloride of sodium) before the introduc- 
tion of the needles. This will diminish the risk of coagulation of blood 
about the joints of the instrument, and it will be injected at the first 
stroke into the patient's circulation. 

By keeping the needles or canula? in situation and manipulating the 
stop-cocks, the blood flows from the arm of the donor into the aspirator, 
from which it is gently sent by the piston (on the reversal of the cock) 
into the veins of the patient. From 5 to 20 ounces may be injected at 
once. 

It may be possible to successfully transfuse blood from one patient 
to another by simply using a flexible bent tube with suitable ends, 
through which the blood will be driven by the force of the donor's 
heart. The greatest possible care should be taken to prevent the 
entrance of air during the operation of transfusion. 

In many cases the direct injection of normal saline solution (0.6 per 
cent. NaCl), in quantities of 20 to 30 ounces, will save life, and, in the 
hands of Hunter, W. H. Brown, of Leeds, and others, has been more 
satisfactory than the transfusion of human blood, which will become 
less and less practised. 



38 ANEMIA. 

Recently Hunter has shown that, for all practical purposes, all the 
advantages to be gained by transfusion may be equally well and more 
readily obtained by injection of a neutral saline — as one drachm of com- 
mon salt to one pint of water. He states that under no circumstances 
are transfusions of milk or other nutritive fluids to be permitted. He 
also strongly points out the great danger of transfusing even defibrin- 
ated blood. 

A glass canula and three feet of tubing and a small funnel is all 
that is needed. 

Blood or saline solution may be injected into the periteneal cavity 
in desperate cases of acute anaemia, and striking effects have been 
obtained by the subcutaneous injection of saline solutions (2 to 3 grains 
to 1 ounce). 

A splendid method is that, recently revived by Antiq, of injecting 
5 ounces of warm defibrinated blood of the ox into the rectum morn- 
ing and evening. Half this amount, viz., a wineglassful, may be used 
at first, mixed with 10 minims of laudanum, till the rectum becomes 
tolerant. 

In ordinary cases of chronic anemia after attention has been paid 
to any habitual hemorrhage or discharge, and where the appetite is 
fair, the physician should attempt to assist nature in restoring the 
blood to its normal state by the administration of iron in some form. 
After a smart saline purge, treatment may be commenced, but if the 
tongue be coated and appetite bad it will be necessary to follow the 
the action of the purge with a tonic. Either of the following will be 
valuable : 

R . — Sodii bicarb g iv. 

Tinct. chirata? . . . . . . • 3J- 

Inf. gentian* ad §x. — M. 

S. — Take a tablespoonful three times a day, after meals. 
Or, 

R. — Acid, nitro-hydrochlor. dil ^j. 

Quininse sulph gr. xlv. 

Tinct. aurantii ^j. 

Aquae ad ^iv.— M. 

S. — Take a teaspoonful with a wineglassful of water three or four times a 
day, before meals. 

Sometimes it will be found advantageous to combine the iron with a 
bitter tonic, as in the following : 



R . — Tinct. ferri chlor. 
Quininre sulph. 
Glycerin, purif. 
Aqua? .... 
jS. — Take a teaspoonful with water thr 



. . . . Siv. 
. gr. xl. 

• ■ . • • 3J- 

. ad §iv.— M. 

ee times a day, after meals. 



ANAEMIA. 39 

It is hardly necessary to remind the student that iron preparations 
should always be given after meals, and diluted. 

The citrate of iron with quinine may be given in 5-grain doses, in 
solution with a little glycerin or syrup and water. The following is a 
good combination : 

R. — Ferri et quininse cit. ...... £jss. 

Tinct. nuc. vom. . . . . . . gij. 

Glycerin, purif. ; . ^j. 

Infus. calumbse ad Jviij. — M. 

S. — A tablespoonful three times a day, after meals. 

Should the anaemia be associated with neuralgia or nerve troubles, a 
teaspoonful of any of the following syrups may be ordered in a wine- 
glassful of water after meals : syr. ferri phosph., quininse et strych., syr. 
hypophosph. comp. (Fellows), syr. ferri phosph. (B. P.). For children 
there is no preparation equal to teaspoonful doses of syr. ferri phosph. 
co. (Parrish). Where struma is present, the syr. ferri iod. or pil. ferri 
iod. (Blanchard) is indicated. 

Constipation being present, 5 grains of the pil. aloes et ferri, morniug 
and night, may be given. 

Should the anaemia be associated with chlorosis or amenorrhcea, 
any of the formulae mention under Chlorosis or Amenorrhoea may be 
given. 

In simple anaemia, where the physician wishes to or a preparation of 
iron as a blood restorative, without running the risk of upsetting any 
of the organs or functions of the body, there are not any preparations 
as pure chalybeates superior to the liquor ferri dialysatus, or to Blaud's 
pills, or to the ferrum redactum. 

Trousseau always insisted upon the superiority of iron filings over all 
other iron preparations, and recently Peter has insisted upon their great 
value when given as a powder mixed with chalk, coffee, and rhubarb. 

The best results are obtained by giving large doses, and often suc- 
cess follows doses much too large to be assimilated in the body after 
small doses had been fruitlessly administered for a long time. (See 
page 424 of the fifth edition of the author's work on Pharmacy, 
Materia Medica, and Therapeutics.) The least bulky preparation of iron 
is the ferrum redactum, and for children the saccharated carbonate is 
a pleasant drug. The former drug may be given in doses of 7 or 8 
grains in a moderately sized pill. 

Much benefit may be obtained by combining arsenic with iron in 
the treatment of anaemia, and this is best done by giving the arseniate 
in combination with reduced iron in a pill, or, better still, by the 
following : 



40 A N JE M I A . 

R . — Tinct. ferri chlor 3 iv. 

Liq. Fowleri ... . . . . . • 3J- 

Glycerin, purif. . . . . . . ^j. 

Aquse ad ifiv. — M. 

S. — Take a teaspoonful in a wineglassful of water three times a day, after meals. 

Where the palate objects to any of the above preparations, a very 
elegant combination is the citrate of iron and ammonia, given in effer- 
vescence with citric acid. 

R. — Ferri et ammon. cit. . . . . . . gij. 

Acid, citric r giij. 

Aqua? . ^viij- — M. 

S. — Take a tablespoonfnl with a tablespoonful of the alkaline mixture three 
times a day, after meals. 

The alkaline mixture contains potassii bicarb, £vj, aquse § viij. 

Teaspoonful doses of the vinum ferri citratis may be given to anaemic 
patients with very feeble digestion. In treating anaemia when feverish- 
ness is present — a very common occurrence after pulmonary or other 
hemorrhage — Basham's mixture (U. S. P.) or the following is very 
suitable : 

R . — Tinct. ferri chlor. . . . . . 3 iv. 

Aquse ammon.. acet. §iij. 

Aquse camphorse . . . . . ad ^ xij. — M. 

S. — Take a tablespoonful four times a day, after meals. 

If headache follows the administration of iron, saline purgatives 
may enable the physician to continue its use, and he may give 5 grains 
of the sulphate with 30 grains of sulphate of magnesia in aerated water 
with advantage. 

The treatment of anaemia should not, however, be confined to the 
official preparations of iron if these do not prove soon satisfactory. 
The natural iron waters of Buxton, Kissingen, Altwasser, Berka, etc., 
may be tried with advantage, and various organic salts of iron, as the 
albuminates of iron, are believed to be more valuable than those in 
combination with the mineral or vegetable acids. The citro-phosphate 
and the sesquibromide and the phosphated pepsin have become fashion- 
able. Cod-liver oil, lactophosphates, malt extract, sea bathing, bracing 
air, and sometimes a short sea voyage and rest from mental work, 
often work wonders. Massage is also a powerful remedy in improving 
nutrition and influencing metabolism, and water charged with oxygen 
gas has found favor with some practitioners. Manganese salts have 
been extolled as remedies for anaemia ; their utility is very doubtful. 
Inhalations of oxygen are preferred to oxygenated water by some 
authorities. 

The treatment of pernicious anaemia with iron is generally most 



ANEURISM. 41 

unsatisfactory, and the only medicine of any value is arsenic, which 
should be freely given in doses beginning with 3 and ending with 15 
minims of the liquor, diluted and given after meals three or four times 
a day. Where arsenic has failed, sometimes phosphorus in doses of 
"A to tV °f a g ram na s given good results. Meyer has recently re- 
ported a very striking success from washing out the stomach only once. 
All the accessory treatment, as Valentine's beef juice, pepsin, malt 
extract, massage, electricity, oxygen, etc., may be tried. 

Lately W. Hunter has made some exhaustive observations upon a 
case of this disease, believing that the coudition is the result of a poison 
(a ptomaine) produced by organisms of a specific nature within the 
gastro-intestinal canal. He recommends the use of antiseptic remedies, 
and selects beta-naphthol as the least soluble and one of the best germ 
destroyers. This is given in doses of 5 grains thrice daily, suspended 
in mucilage. He has also discovered that the blood destruction is 
greatly diminished by the use of a farinaceous diet, and increased by 
nitrogeneous food, hence the value of starches and fat as a diet. 

ANEURISM. 

The treatment of aneurisms depends upon their situation, magni- 
tude, etc. Those outside the reach of the surgeon may be treated 
medically, and numerous proofs of the complete cure of abdominal and 
thoracic aneurisms have been recorded. The writer has dissected a 
thoracic aneurism which underwent complete solidification when under 
medical treatment some time previously, death having taken place as 
the result of phthisis after perfect cure of the tumor. 

This is spoken of as Tufnell's treatment, the chief element in which 
is absolute and total rest for a period varyiug from three to six months. 
The patient is kept in bed, aud on no account permitted to sit up even 
for an instant, though he may be permitted to turn occasionally from 
side to side with slowness and deliberation, the object being to so quiet 
the circulation that spontaneous coagulation may take place in the sac. 
The diet is to be carefully restricted. The total allowance of solid food 
is not to exceed 10 ounces daily, which may consist of well-cooked 
meat or fish and biscuit, and liquid nourishment to the amount of 10 
ounces of milk is allowed. As a rule, stimulants are forbidden. The 
bowels are carefully regulated, and complete repose of body and mind 
as far as possible secured. 

There are several drugs which have been believed to be of value in 
quieting the circulation and promoting coagulation. Chief among 
these is iodide of potassium, which must be given in full doses (10 to 
30 grains three times a day) for several weeks. Acetate of lead has 
been used, but with apparently less benefit. 

Digitalis has been from time immemorial employed to diminish the 
force of the circulation in treating patients with internal aneurism, but 
it has gradually fallen into disuse as its powerful cardiac tonic proper- 
ties have been demonstrated. Aconite and veratrum viride have been 

4 



42 ANEURISM. 

employed to quiet the heart's action, but their administration can only 
be carried out for a short period without doing serious mischief. 

Lately -J-grain doses of chloride of barium have been strongly recom- 
mended. 

Iron may be used alternately with the iodide treatment, as it is an 
important matter to have the quality of the blood up to the standard, 
thereby favoring coagulation. 

After a short time the heart's action settles down into complete regu- 
larity with a slower and weaker pulse, and, if everything prove favor- 
able, coagulation of the blood in the sac takes place. Mercurial 
inunctions have proved useful, in conjunction with iodides, in syphilitic 
aneurisms. 

Where coagulation does not occur a variety of treatments have been 
tried, and generally with fatal results. In the present state of our 
knowledge there cannot be said to be any of these lines of treatment 
specially worthy of recommendation : 

1. Hypodermic injection of ergotine, with a view to cause contraction 
of the muscular coat of the aneurism and condensation of the tissues 
surrounding the sac. It sometimes does diminish the size of the tumor, 
but Broadbent has shown that it is not by acting u pon the muscular fibre. 

2. The injection of coagulating liquids, chiefly the chloride of iron. 
For internal aneurism this is unjustifiable, as there is danger of emboli 
and the risk of setting up sloughing in the sac and inflammation in 
surrounding parts. (It may, however, be useful in small varicose and 
cirsoid aneurisms.) 

3. Acupuncture by fine needles, or the introduction of foreign bodies 
into the sac to cause coagulation — as horsehair, steel wire, watch 
springs, catgut, etc. The results have been most unsatisfactory, and 
nearly always fatal. 

4. Galvano-puncture. This is carried out in a variety of ways. The 
best method being the insertion into the sac of two needles insulated 
with vulcanite except near to their points, the uncoated parts within 
the sac being so inserted as to be a considerable distance apart, the 
needles are then connected with the wires of a battery giving a low 
tension current, and the electric fluid permitted to flow between the 
needle points till coagulation of the blood in the sac results, as evidenced 
by the alteration in the shape and pulsation of the tumor. Sometimes 
only the needle connected with one pole, either negative or positive, is 
inserted whilst the opposite pole is applied outside the sac or to the skin 
in its vicinity. 

Some cases of cure have, undoubtedly, followed this method of 
treating internal aneurisms ; but, upon the whole, the results are far 
from satisfactory, and fatal inflammation, sloughing, and hemorrhage 
have followed. 

It has been suggested that lecithin might be injected into the outer 
coats of the aneurism, with the view of favoring coagulation. This 



ANGINA PECTORIS. 43 

substance is found as a constituent of the red blood-corpuscle ; it may 
be regarded as a glycerophosphate of neurin. 

The pain of internal aneurisms may be lessened by narcotics like 
opium, morphia, and Indian hemp ; and large doses of iodide of potas- 
sium sometimes give relief and render life bearable. 5 grains of anti- 
pyrine or 3 grains of antifebrin often relieve distress in a remarkable 
way without producing any bad consequences, and their administration 
may be continued for a long time. 

Where the aneurism is upon any of the limbs within easy reach, 
there is good chance of a cure by some of the following methods : 

1. Pressure upon the main trunk — digital or instrumental. 

2. Rapid pressure under anaesthetics. 

3. Local pressure upon the sac. 

4. Ligature — proximal and distal. 

5. Extirpation. 

6. Manipulation. 

ANG-EIOLEUCITIS— See Lymphangitis. 
ANGINA PECTORIS. 

Attention should be directed to measures with a view to cut short the 
attacks, and, secondly, to remedies for administration during the attack 
with a view to prevent its recurrence. 

During the attack, or as soon as warning of its approach is felt by 
the patient, there is no remedy to compare with nitrite of amyl for 
rapidity of action and certainty of effect. The best way to use it is to 
break one of the silk-enveloped, fragile glass capsules, made by Mar- 
tindale, and hold it under the patient's nose so that he may inhale the 
vapor. Each capsule contains from 2 to 10 minims. Those containing 
5 minims will be found the best for all practical purposes. Generally 
the attack is immediately arrested after the first few deep inspirations. 
Other nitrites may be employed, but the delay in their action, though 
but of a few minutes' duration, is a serious drawback to their use when 
the patient is struggling under the agony of an attack. Other measures 
must not be omitted. All constriction about the chest and neck must 
be removed, and the patient supported in the position which affords 
him the most relief. A rapid diffusible stimulant, like sal volatile or 
brandy, may be given — a large dose of spirit of nitre is the best — and 
warmth to the extremities may be tried. If there be a full stomach, 
or ineffectual attempts to vomit, a rapid emetic (30 grains of sulphate 
of zinc) will be useful. 

The amyl may be administered by the mouth. The following is a 
good formula for use in teaspoonful doses in hot water : 

R . — Amyl. nit. . . .... ^j. 

Alcohol ^ix. 

Glycerini . . . . . . . . ad J iv. — M. 



44 ANGINA PECTORIS. 

Where there is warning given to the patient a few minutes before 
the attack, nitro-glycerin in solution or tablet may be administered by 
a method to be mentioned presently. 

In the intervals between the attacks, attention should be paid to 
everything that improves the health. If the angina is found to depend 
upon organic lesion of the heart, suitable treatment should be directed 
to the affection ; if of a purely neuralgic character large doses of iodide 
of potassium, or iodide of sodium, will be useful. The value of these 
drugs in angina pectoris has hardly been sufficiently appreciated. In 
the writer's hands he has seen 15 grains thrice daily relieve pain and 
tension very decidedly. If there be reason to suspect disease of the 
coats of the aorta and large vessels, iodides are especially indicated. 
In those patients where an attack of indigestion brings on the angina, 
remedies directed to correct this are clearly indicated. Arsenic is often 
of value in those cases where the attacks are very infrequent and not 
severe. Full doses (5 minims) of Fowler's solution should be given 3 
times' a day after meals for many weeks or months. 

Phosphorus has also a good reputation given in doses or -g^- to y-g- 
grain. It may be given alternately with the arsenic, and it is a good 
plan to give arsenic for one month and phosphorous during the next. 

Cocaine has been found to possess the power of warding off the 
attacks of angina when given in doses of I grain three or four times a day. 
Lashkevitch tried it in several cases associated with organic heart 
troubles, and found it caused the attacks to disappear entirely. The 
writer has never used the drug in angina. 

Where the attacks come on often and severe, nitrites must be resorted 
to in order to make life bearable, and a knowledge of the pharmaco- 
logical action of the different members of this class is of the greatest 
use to the physician in dealing with these cases. Thus the rapidity 
with which nitrite of amyl relieves the spasm, by causing dilatation of 
the vessels, is the great drawback to its usefulness when we come to 
deal with the case in a more permanent way, as it is proven that its 
effects pass off as rapidly as they come on, and after a very few minutes 
the amyl leaves no evidence of its action upon the vessels. 

Nitro-glycerin is much more lasting in its effects, whilst Hay and 
Leech have shown that the action of nitrite of sodium is still more 
persistent. Consequently Avhen the physician wishes to keep the 
abnormal high tension down for any length of time, he will select a 
substance more persistent in its action than amyl. The writer has, 
however, found by clinical experience, that much better results can be 
obtained by giving a very small and oft repeated dose, and he believes 
that in this lies the way to a successful treatment of angina. 

Thus the ordinary dose of nitro-glycerin is about TW to sV grain (or 
1 to 2 minims of the 1 per cent, solution) three times a day. Generally 
marked dilatation of the vessels and flushing of the face follow soon 
after each dose, but in an hour afterward nothing remains but severe 
headache and some malaise, and hours before the next dose is due the 



ANGINA PECTORIS. 45 

tension in the vessels has assumed its usual abnormal height, and the 
next attack due comes on with certainty and in no way modified by the 
previous dose. His plan is to divide the daily amount (ordinarily given 
in 3 or 4 doses) into about .30 small doses, one to be taken every half- 
hour during the day. This is easily done by dividing the official tablets 
into fragments, or by getting tablets made containing yoVg- grain each. 
The official tablets are too small in bulk and too powerful. 

The patient does not, as a rule, object to slipping a fragment into his 
mouth every 15 or 30 minutes, especially as he soon learns that he 
avoids the severe headache and prevents the attacks taking place, and 
he soon learns to shorten or lengthen the interval as his experience of 
the premonitory symptoms enable him to judge of the probability of 
an attack. It is thus easy to obtain all the benefits we wish from the 
drug without producing marked flushing of the face, or throbbing of 
the vessels of the neck, or headache. 

Nitro-glycerin acts as a nitrite, the nascent nitrous acid formed in 
the blood from its decomposition being more active than the nitrous 
acid of the nitrites. 

Nitrites of sodium and potassium may be given in angina, and their 
dosage and administration can be carried out in the same way as sug- 
gested about nitro-glycerin. It is not convenient, however, to administer 
a dose of liquid medicine every fifteen or thirty minutes to a patient 
going about the ordinary duties of life, and, hitherto, these remedies 
have been only given in solution, in doses varying from 1 to 4 grains, 
every four or six hours. A small lozenge, containing i grain of either 
salt, might be taken every half hour with advantage. 

Chloral, ether, and chloroform have been recommended to relieve 
pain and distress in angina, but their use is not to be recommended, 
especially chloral, from its dangerous depressant action upon the heart. 
Inhalations of oxygen have been advised, but nitrites or nitro-glycerin 
will generally meet all indications. Cold lotions or ice to the forehead, 
and mustard and turpentine to the chest, may give some relief to the 
paroxysm in the absence of amyl. 

Quinine has been said to relieve angina in malarial cases. Pyridine 
inhaled, or by capsule, or in water, 10 minims, has given instant relief. 
Bromide of ethyl has been recommended by Squire. Atropine, bella- 
donna, hyoscyamus, tobacco, and lobelia have occasionally given relief 
when the patient could not tolerate the action of the nitrites. 

The application of the continuous current, beginning with 15 and 
going up to 20 or even 25, Leclanche elements, with the negative pole 
on the nape of the neck and the positive pole placed over the lower 
half of the sternum, has been followed with very satisfactory results in 
some cases, and is always worth careful trial. Some prefer to only 
galvanize the sympathetic upon the left side. 



46 ANUS, FISSURE OF. 

ANUS, Fissure of. 

This painful affection, when of very long standing, must be dealt 
with by the knife. An incision may be made by drawing the knife 
across the middle of the fissure or small ulcer, dividing about a third 
of the fibres of the external sphincter, the bowels having been pre- 
viously well opened, and the sphincter thoroughly dilated under an 
anaesthetic. The after-treatment is carried out upon the same principles 
as after operation for fistula. 

Some surgeons deal with the fissure by forcible dilatation of the 
sphincter with the thumbs, or Ball's new operation may be performed. 

Touching the ulcerated spot with the thermo-cautery, or, better still, 
with the galvano-cautery, is often enough to effect a rapid cure. The 
bowels must be kept soft by a well-regulated diet, or by the adminis- 
tration of one large dose of olive oil daily, or a teaspoonful of sulphur 
or castor oil at bed-time. 

If the case be not very chronic, and not much thickening of sur- 
rounding tissue has occurred, the application of a strong caustic to the 
fissure or ulcer may be followed by new action being set up, which may 
end in healing. 

1. Nitrate of silver. This is followed by such severe pain, and 
sometimes inflammation, that it should never be recommended. 

2. Solution of chloride of zinc, 1 : 8. The stick has been used. 

3. Pure carbolic or nitric acid. The first is decidedly less painful 
and more effectual. 

Ice should be kept in contact with the anus for some time afterward 
and a morphia suppository be inserted, and a 4 per cent, cocaine solu- 
tion should be previously applied for some time to ensure complete 
anaesthesia. 

In ordinary cases of anal fissure the chief matter to see to is the 
aganizing pain and pruritus after defecation, and a host of anodynes 
have been recommended and praised, the vast majority of which are 
utterly worthless. The following are a few formulae which may be 
useful : Ext. belladonnas, 1 drachm ; unguenti, 1 ounce. Or, unguen- 
tum gallae, 1 ounce ; pulv. opium, 1 drachm. 

Or, 

Be. — Cocain. hydrochlor gr. xij. 

Aquse . . 3j. 

Lanolini §j. — M. 

R. — Ext. Kramerise 3J- 

Glycerini giij. 

Lanolini £j. — M. 

R . — Bisrnuthi subcarb. ^ -r • -jyj 

Glycerini q. s. ut fiat pasta J 



ANUS, FISTULA OF. 



47 



1£. — Glycerin, acid. tan. ..... 


. M- 


Chloroformi 


. 5j.— M. 


K • — Iodofomii 


• 3j- 


Yaselin 


• gj.-M. 


R. — Hydrarg. c. creta 


gr. xxx 


Unguent i 


■ 3J--M. 



This list having often failed with the writer, he was led to try 
conium, and after repeated failure with the worthless extract of the 
B. P., he obtained surprising effects with an ointment prepared in the 
following manner : 

Two ounces of the Pharmacopoeial juice are place in a small evapo- 
rating dish, and permitted to evaporate slowly at a heat under 150° F. 
till the bulk is reduced to about one and a half or two drachms. This 
can be done by placing the dish on the top of an ordinary domestic 
hot-water cistern for twenty-four or forty-eight hours. The syrupy 
liquid is then carefully triturated with as much lanolin as will make 
the weight up to one ounce ; the result is a perfectly smooth adhesive 
ointment of a light brown or dark fawn color and stable. 10 grains of 
the persulphate of iron may be added in suitable cases, as recommended 
by Cripps. 

The ointment appears to paralyze the endings of the motor nerves 
distributed to the fine muscular layer under the surface of the mucous 
membrane ; the reflex twitchings of this layer keep up the perpetual 
pain and uneasiness in diseases of the rectum and anus associated with 
abrasions, ulcerations, or fissures. At the same time the sensory ter- 
minals are paralyzed. After many trials the writer is satisfied that 
this will be found by far the best remedy for the pain of fissures and 
ulcerated hemorrhoids, and he has seen anal fissures heal under its use. 
It should be inserted well up into the bowel. 

The following ointment has been much praised recently. It may be 
tried where other measures fail to give relief: 



R. — Cocain. hydrochlor. 
Acidi borici 
Lanolini . 



gr. xxx. 
• 3Jss. 
ad gij.— M. 



ANUS, Fistula of. 

Though in the vast majority of cases of anal fistula a cure is not to 
be expected unless with the aid of the knife, nevertheless, in recent 
cases before resorting to incision, some faint hope of less severe meas- 
ures being successful may be entertained. If there be a free opening 
of the fistulous tract into the bowel at one end and through the skin 
at the other, it will be found waste of time trying to cause healing of 
the sinus without a free incision. In attempting to effect a cure with- 



48 ANUS, FISTULA OF. 

out the knife the surgeon may endeavor, in blind external fistulse, 
to excite a new action in the fistula. This may be done by passing a 
probe dipped in strong solution of chloride of ziuc, or in pure carbolic 
acid. Nitrate of silver causes so much pain and inflammation that it 
should not be used. 

The injection of weak tincture of iodine by a fine syringe is some- 
times followed by closure of the sinus, but the writer strongly recom- 
mends the injection of the compound tincture of benzoin, as being 
antiseptic and stimulating and free from danger, and does not cause 
much pain. The galvano-cautery may be rapidly passed through the 
fistula. Whatever plan tried by the surgeon to cause -healing of the 
sinus will end in failure if free drainage be not established. Mr. Cripps 
accomplishes this by inserting a little plug of gutta-percha, shaped by 
the fingers like a miniature mushroom. The stem is pushed into the 
fistula, and the flattened head kept in position by a little plaster ; this 
soon widens the orifice, and permits free escape of pus. This line of 
treatment, though tedious and often very unsatisfactory, should be 
resorted to in those cases where the fistula is associated with some 
serious or fatal disease, as phthisis, diabetes, or hepatic cirrhosis. 

Failing cure by the above method the surgeon proceeds, after clear- 
ing out the bowel, to pass a probe-pointed director from the outer to 
the inner opening, the point of the director is then hooked down by the 
finger from within the bowel and made to project through the anus, 
and with one clean incision all the parts between the groove in the 
director and the mucous membrane as divided by a curved bistoury. 
Should there be a cul-de-sac running beneath the mucous membrane 
above the internal opening it had better be also laid open at the same 
time. If the internal opening is so far up that the point of the director 
cannot be brought down through the anus, the tissues may be divided 
by passing one blade of a fine probe-pointed pair of scissors into the 
groove on the director, and the other blade into the anus, and cutting 
the intervening tissues. Some surgeons go further than this, and dis- 
sect out the lining membrane of the sinus and any diseased tissue 
appearing in the wound. This can be very seldom required in ordi- 
nary fistulse, as the wound heals from the bottom in a short time. 

By inserting a flat piece of soft, smooth wood into the rectum, and 
passing a shap-pointed bistoury along the groove in the director as it 
lies in the sinus with its point free in the rectum, the point of the bis- 
toury, guided by the director, may be firmly sunk into the wood, and, 
both being withdrawn together, the intervening tissues are divided. 

Those cases in which no internal opening is found are often sadly 
bungled in the treatment, the operator making an internal opening 
which may be a long way off the tract of the fistula. The best method 
to pursue in such cases is to introduce the probe as far as it will go 
through the external opening, and dissect up the fistulous tract bit by 
bit, and follow out any side tracts in the same way. 

Longo insists upon the entire excision of the fistulous structure and 






49 

the union, by first intention of the outer surfaces, unless there be hem- 
orrhoids, or when the internal opening is very high up. In all cases 
of fistula in phthisical patients, where an operation is justifiable, the 
tract should be scraped or touched with the thermo- or galvano- 
eautery. 

A pad of lint, greased with boric or iodoform ointment, is inserted 
into the bottom of the wound, which is allowed to granulate from the 
bottom. The bowels should not be allowed to act till the fourth or 
fifth day, and then only by a dose of castor oil. 

ANUS, Prolapse— See Prolapsus Ani et Recti. 
ANUS, Pruritus of. 

In order to treat this troublesome affection successfully, it is neces- 
sary to determine if the pruritis be caused by some focal irritation, as 
thread-worms, fissures, ulcer of anus, or hemorrhoids. If any of these 
causes are present suitable treatment must be at once undertaken, and, 
as a rule, the itching will disappear upon the removal of the cause. 
Many cases of pruritus do not depend upon any such irritation, being 
but the local expression of a well-marked neurosis, and, in these in- 
stances, arsenic, quinine, phosphorous, tonics, salicylates, antipyrine, or 
antifebrin should be given. The general health and bowels must be 
closely looked after, and local treatment directed to allay the extreme 
irritability of the peripheral nerves. 

There is no better remedy than conium ointment, carefully prepared 
from the author's formula on page 47. 

Cocaine gives short relief, and morphia suppositories — with or with- 
out belladonna — though they may relieve the itching for a time, often 
appear to aggravate it. 

An ointment containing creasote or carbolic acid, 1 drachm ; lard, 2 
ounces ; camphor, 1 drachm ; is a safe and often effectual remedy. 
Where ointments do not afford relief, the writer has seen marked 
benefit from dusting very freely the parts in the neighborhood of the 
anus with subcarbonate of bismuth. Lotions are seldom successful. 
When ointments fail, the following may be tried : 



R. — Pulv. boracis . 
Aquae menth. pip. 



• 3 iY - 
ad % xx.— M. 



R. — Chloral, hydrat gij. 

Aquae rosse ^ x. — M. 

Or, 

R . — Zinci oxidi % iv. 

Glycerin! gj. 

Aquae ad ^x.— M. 

Friction and scratching should be particularly avoided. 



50 ANUS, IMPERFORATE — APHONIA. 

The constant current, 10 Leclanche cells, may give marked relief, 
and at bedtime a small enema of 3 to 5 ounces of cold water, often acts 
like magic. 

ANUS, Imperforate. 

Sometimes the obliteration of the anal opening may be caused by ad- 
hesions of the epithelial layers around the anus, which can be easily 
remedied by tearing them open upon forcibly separating the nates. If 
there be no deficiency in the rectum, the bulging of the thin septum 
closing the anus being apparent, a free crucial incision will permit of 
the escape of the meconium, and subsequent dilatation with the finger 
will remedy the matter. 

If, however, no bulging be evident, and there are signs that the 
lower portion of the rectum is absent, a dissection, beginning with an 
incision in the middle line behind the posterior margin of the anus, 
must be carried backward and upward until some bulging is observed. 
Sutures should connect the lower part of the newly discovered rectum 
to the margins of the skin wound on each side, and the bulging part 
be freely incised. It is of the greatest importance to carry the dissec- 
tion far enough to permit suturing of the bowel to the skin, if possible, 
thereby preventing cicatricial contraction or stricture, and for this 
purpose a portion of the coccyx may be removed. Should the rectum 
not be reached by dissection from below, there is nothing open to the 
surgeon but to make an artificial anus, opening the bowel by Araus- 
sat's operation in the left loin, or in the left groin by Littre's method. 

APHASIA. 

The treatment of this condition will for the most part be included in 
the treatment of the hemiplegia, with which the defect of speech is 
usually associated. Absolute rest of body and mind, with very re- 
stricted animal diet and mild purgation, associated with treatment 
directed to the original lesion causing the hemiplegia, will be all that 
the physician can do. Should all traces of the hemiplegia pass away, 
and there be evidence that the patient, though aphasiac, retains his 
mental faculties still unimpaired, he may be taught to speak, and in- 
stances are recorded where recovery has been in this manner made 
complete. 

APHONIA 

depends upon causes which prevent the vocal cords meeting, hence its 
treatment may in one case be the treatment of paralysis of the ad- 
ductors, or of any organic lesion as tumor, ulceration, anchylosis of 
cartilages, etc. Generally, however, complete aphonia comes under 
the eye of the physician as a manifestation of hysteria, and its cure is 
rapid and satisfactory. A strong induced current is the remedy for this 
affection. One wire of the battery is attached to a flat electrode, which 



APHTHAE — APOPLEXY. 51 

is made to rest upon the outer surface of the larynx, whilst the other 
wire is attached to a laryngeal electrode mounted on a handle, contain- 
ing a small contact breaker. This electrode is inserted into the space 
between the cords, and the current turned on by pressing the button 
in the handle so as to produce a painful and severe shock, after which 
the patient may immediately cry out with a strong voice. Occasion- 
ally the application of the shock must be repeated. The continuous 
current is useless, and so also is a weak induced current. Sometimes 
the passing of a smart induced or interrupted current across the larynx, 
by applying a pole to each side of the external surface of the larynx, 
is enough to restore voice. (See under Hysteria.) 

The writer has witnessed the successful treatment of hysterical 
aphonia by intoxicating doses of alcohol — a most objectionable and 
unjustifiable proceeding. Atropine and belladonna, pushed to the 
extent of producing their physiological actions, have been employed, 
but electricity fulfils every indication. Strong solutions of nitrate of 
silver, 3J to 1 ounce, or of chloride of iron, gj to 1 ounce, have been 
applied with a brush to the larynx with rapid improvement. 

For the treatment of hoarseness, see Laryngitis. 

APHTHA OR APHTHOUS STOMATITIS. 

The physician should see to the absolute cleanliness of all bottles or 
vessels used by hand-fed children. The local application of the old 
glycerin of borax is the best remedy. (Powdered borax, 1 ounce ; 
glycerin, 4 ounces.) A little placed on the tongue or brushed upon 
the lining membrane of the mouth every hour or two, is fatal to the 
life of the o'idium albicans, upon whose presence the affection depends, 
and a speedy cure generally results. Borax and honey may be used, 
or a small quantity of powder, consting of powdered borax and sugar, 
may be dusted upon the aphthous ulcers frequently. A weak solution 
of chlorate of potassium (1 in 50) is also very effectual. Should the 
ulcers be deep or show any signs of spreading, as they may do in 
weak, bottle-fed children, they should be touched with nitrate of silver 
or nitric acid, or a strong solution of sulphate of copper or alum. If, 
notwithstanding this treatment, the aphthae continue to increase, the 
food of the infant should be changed, or a healthy wet-nurse obtained. 
An occasional dose of Gray powder will do good, and, if there be much 
prostration, small quantities of brandy may be given, or quinine may 
be indicated with minute doses of iron should diarrhoea be present. A 
few grains of boric acid, added to each pint of milk, is most valua- 
ble. (See under Stomatitis.) 

APOPLEXY. 

The treatment will depend upon the nature of the lesion causing the 
seizure; in the absence of information, it may be wise to regard every 
case as caused by cerebral hemorrhage. Rest and absolute quiet are 



52 APOPLEXY. 

essential, and it is a serious mistake to carry the unconscious patient 
up or down stairs, or to any distance. He should be placed in a bed 
in the room in which his sickness began, when this is possible. His 
clothes should be removed with slowness and care, a nurse or assistant 
taking charge of his head while this is being done. Placed upon his 
back upon a hard mattress, his head and shoulders should be elevated, 
and all constriction about the neck removed, and his face turned to 
one side so that the tongue shall not fall directly backward, and 
impede the breathing. 

A smart purge should be given, especially if it can be known that 
constipation is present, and 5 grains of calomel, or 1 minim of croton 
oil, placed upon the tongue, will find their way into the stomach. 
Stimulants, always given upon these occasions, should be avoided, and 
no nourishment should be administered until the ability to swallow 
returns. If the pulse be bounding, and the carotids throbbing, and 
signs of high arterial tension be evident, the physician should not hesi- 
tate to bleed at once. By incising the vein in the arm, and allowing a 
full stream to flow from a large opening, further cerebral hemorrhage 
will be prevented. Leeching or cupping is worse than useless. 

If the head is hot, ice should be applied to the forehead, and no 
harm can be done by mustard to the back of the neck. Shaking of 
the patient, and attempts to arouse him by shouting or flaggellation, 
are unpardonable, and the physician must abstain from further active 
treatment, and await events. The lips may be moistened with a little 
water or glycerin of borax, and if the period of unconsciousness be 
prolonged, enemata of eggs and milk may be given. It is wise to ab- 
stain from all animal food for a considerable time after swallowing 
power returns. As a rule, the remedies indicated in other hemorrhages, 
as in haemoptysis, are useless, though some authorities recommend ergot, 
acetate of lead, gallic acid, digitalis and even opium. This latter should 
seldom or never be given. 

Sometimes the physician may chance to see a patient whose pre- 
monitary headache and drowsiness may warn him of an approaching 
attack, especially if an attack of apoplexy or hemiplegia, or previous 
symptoms of softening had occurred in the same case ; by brisk purg- 
ing or blood-letting, and the treatment just mentioned, the attack may 
be warded off. 

After consciousness returns, the most rigid silence and repose must 
be maintained, and any reaction, as shown by flushing of the face or 
headache and feverishness, must be met by ice to the head and a 
diaphoretic, small doses of aconite, combined with bromide of potas- 
sium, being very useful. At a later stage, the bromide, combined with 
iodide, may facilitate the absorption of extravasated blood, and small 
doses of arsenic may be given along with these remedies. 

If there be evidence of syphilitic disease of the cerebral arteries, 
mercurial ointment should be rubbed in at once and continued until a 



ASCARIS LUMBRICOIDES — ASCITES. 53 

decided impression is made upon the system ; afterward large doses of 
iodide of potassium should be given. 

Victor Horsley has strongly recommended the heroic proceeding of 
ligaturing the common carotid artery in ordinary apoplexy in order to 
stop the hemorrhage ; he goes even further, and states his conviction 
that the operation should be done -as a prophylactic measure in cases 
where the patient has already had a slight hemorrhage. 

ASCARIS LUMBRICOIDES. 

The remedy for the round worm is santonin ; seldom need any other 
drug be administered. By far the best way is to mix the powder in 
castor oil, and give it in doses of 2 grains to a child three years old 
and upward ; rarely will adults require more than 5 grains. If purga- 
tion does not follow in six or eight hours, a saline cathartic or senna 
may be given. In the case of children who will not take castor oil, 
santonin may be mixed with butter, and spread upon a slice of bread, 
and since it is always best to give a purgative along with it, 2 or 3 
grains of calomel may be sprinkled upon the butter. The writer has 
found that syrup of senna makes a splendid vehicle, and almost every 
child will take the mixture. If purging does not follow, more syrup 
may be given in six or eight hours. Santonin is also given in a 
powder mixed with scammony or rhubarb or jalap — an unnecessary 
and nauseous combination. 

Yellow vision and orange-red discoloration of the urine very often 
result, but soon pass off. It should be always borne in mind that san- 
tonin in large doses is a dangerous drug, liable to produce cerebral 
symptoms, and the lozenges should not be left in the way of young 
children. Castor oil certainly minimises the danger of untoward 
effects. 

Sulphur, spigelia, turpentine, male fern, kamala, and kousso, and 
various Indian vermicides are recommended, but santonin never fails. 
It should be given for twc or three days in succession. 

ASCARIS MYSTAX, 

a smaller round worm, is destroyed as readily as the large round is by 
santonin given in the same manner and dose. 

ASCITES. 

The treatment of the many different diseases which cause ascites will 
be mentioned under the heading of each affection. For convenience 
the following survey is here given : 

1. If the ascites be caused by the presence of malignant or other 
tumors upon the trunk of the vena porta outside the river, obstructing 
the flow of blood through the vein, little can be expected except pal- 
liative treatment. 

2. If the obstruction be within the liver as in cirrhosis (by far the 



54 ASCITES. 

most common cause), abstinence from all stimulants and irregular 
living, the free use of saline cathartics, regularity of diet, with open- 
air exercise and change of climate or scene, and a course of mineral 
acids (nitro-hydrochloric), afterward followed by iodides and sea- 
bathing, may effect removal of the fluid if the cirrhotic change has not 
proceeded too far. 

The same lines, in the main, may be pursued where perihepatitis is 
the cause of the ascites. 

Where the ascites results from the pressure of syphilitic gummata in 
the liver-substance or in the transverse fissure, mercurial treatment, 
followed by very large doses of iodides, is indicated. . 

Where amyloid disease in a similar way is producing the accumula- 
tion, the removal of the cause of the amyloid affection (prolonged 
suppuration or syphilis) should be attempted. Cancerous masses inside 
the liver may cause ascites, which can only be reduced by tapping. 

3. Obstruction of the vena cava inferior, or of the hepatic vein, is 
generally outside the range of curative treatment. 

4. Ascites may be a part of the general dropsy of Bright's disease, 
when purgatives, diuretics, and hot-air baths will be indicated. (See 
Bright's disease.) 

5. Chronic peritonitis, secondary to some primary affection, as rup- 
ture of a cyst, ulcers in the bowels or stomach, tubercle or cancer, 
must be treated by attention to the underlying cause, or, failing this 
by tapping. 

6. Diseases of the heart causing serious interference with the circu- 
lation in the large veins, leading to ascites, must be combated by reme- 
dies which aid compensation and strengthen the muscular power of the 
ventricles and auricles, as digitalis, broom, strophanthus, etc., assisted 
by purgatives and diuretics. 

7. When changes in the lung lead to embarassed circulation and 
ascites, little can be done except in the way of palliation. Accumu- 
lation of a large amount of pleural fluid can be easily remedied by 
tapping with the fine trocar introduced by Southey, or by the aspirator. 

Given ascites from any of the above-mentioned causes which fail to 
disappear after our attempts to strike at the primary affection, we may 
proceed to treat the ascites itself, regarding it as a local dropsy, and 
endeavor to produce its absorption — 

1. By acting upon the local absorbents with rubefacients or counter- 
irritants, such as iodine or small blisters (a most unsatisfactory method), 
or by rubbing in the lin. potas. iod. cum sapone, B. P. 

2. By purgatives — chiefly salines, elaterium, jalap, or croton oil. 

3. By diuretics — like digitalis, copaiba, broom, Guy's pill, or calo- 
mel. 

3. By diaphoretics — as hot-air baths, acetates, etc. 

5. By absorbents — like iodide of potassium, which stimulate the 
lymphatics and tend to absorb effused products. 

6. By tapping. 



ASTHENOPIA. 55 

This latter method of treating ascites has for its object two very dis- 
tinct aims : 1. To give relief where the amount of the accumulation is 
so great as to cause serious discomfort. 2. To cure the ascites where 
this is not depending upon a fatal cause. Thus life may be prolonged 
by tappiug in ascites caused by cancer, and the ascites may be cured 
completely by repeated tappings in cirrhosis of the liver, as proved by 
Roberts and others, and witnessed by the writer upon several occa- 
sions. 

The operation is a very simple one, and may be performed with an 
ordinary trocar and canula. After evacuation of the contents of the 
bladder, a broad binder is passed round the abdomen, and the ends 
grasped by two assistants, who keep up pressure as the fluid flows by 
pulling upon the ends of the bandage. By making a hole in the ban- 
dage opposite the middle line, and half way between the umbilicus and 
pubes, the site of puncture is exposed, and with a good sharp plunge 
the canula and trocar are driven through the abdominal walls precisely 
in the middle line, and half way between the pubes and umbilicus, the 
surgeon having satisfied himself previously that absolute dulness was 
present in this region. Upon the withdrawal of the trocar fluid will 
continue to run till the peritoneal cavity is emptied, and the pressure 
of the bandage will prevent syncope or weakness during the operation 
and after, as it should be tightly fastened and left on after the canula 
is withdrawn, and the puncture closed with a little plaster or collodion, 
or covered with lint greased with carbolic oil. 

The patient, if weak, may be in bed in the recumbent posture ; 
usually it is more satisfactory to have him seated in an arm-chair with 
the pail for the reception of the fluid between his knees. 

The aspirator may be used, but it is wholly unnecessary. Southey's 
tube, which is a fine trocar and canula with several feet of India- 
rubber tubing attached, is a most desirable instrument for tapping the 
abdomen. It may be left in situ for many hours, and by dropping the 
free end of the tubing into the pail under the surface of the liquid, 
the fluid contents of the peritoneal sac can be safely, slowly, and pain- 
lessly syphoned away without danger of syncope, hemorrhage, or peri- 
tonitis. 

After the removal of the fluid, by the judicious use of iodine with 
moderate pressure externally, and purgatives and diuretics internally, 
the reaccumulation of the fluid may, in some instances, be prevented. 

ASTHENOPIA. 

If the weakness of sight depends upon hypermetropia through ex- 
haustion of the over-worked ciliary muscle in attempting to remedy the 
focus of parallel rays falling behind the retina, absolute rest to the eyes 
must be insisted upon for a time. Such measures as improve the gen- 
eral health should be prescribed, and the effort at accommodation 
should be made easy by the use of properly selected convex spec- 
tacles. 



56 ASTIGMATISM — ASTHMA. 

The treatment of asthenopia, caused by insufficiency or weakness of 
the recti muscles, will consist in the correction of any errors in refrac- 
tion which may be present, after which the defective power of the recti 
can be overcome by suitable prisms. 

Where the asthenopia is retinal or depending upon some exhaustion 
of the general nervous system, as may be seen after recovery from 
serious illness, the eyes should, as far as possible, be rested from all 
close work, and, if there be any photophobia, light should be modified 
by the use of smoked glasses. Every means of restoring the general 
health should be attended to, and the treatment recommended for 
amaurosis be used, i. e., hypodermic injection of strychnine, with iron 
and quinine internally at the same time, or large doses of Easton's 
syrup may be prescribed. The spasms of accommodation may be 
relieved by cocaine or atropine occasionally dropped into the eye. 

ASTIGMATISM 

can only be remedied by the use of cylindrical lenses, which correct 
the unequal refraction of entering rays in the two chief meridians. 
There is extreme difficulty in correcting irregular astigmatism. 

ASTHMA. 

The treatment of this troublesome affection will resolve itself into 
the management of the case with a view to prevention of the attacks ; 
and, secondly, to the exhibition of remedies with a view to affording 
relief in the attack of bronchial spasm. These two lines of treatment 
will often necessarily overlap each other, as the remedies which will 
effectually prevent the actual attacks will sometimes give speedy relief 
when the paroxysm is already established. 

The preventive treatment of asthma will resolve itself into a careful 
examination of the cause or causes at work in bringing on attack. The 
avoidance of such causes sometimes settles easily the entire problem of 
treatment, as may be seen in those cases where the attacks are brought 
on by the inhalation of light dust from feathers, and by breathing air 
charged with various irritating vapors and emanations. 

Atmospheric or climatic cause is very striking in many instances, and 
it is remarkable how asthmatics can live in perfect freedom in the close 
air of large cities, whilst a journey into the pure, clear atmosphere of the 
open country or seashore at once brings on a series of severe and distress- 
ing attacks, only to be successfully treated by a return to the smoky city 
air. In comparatively rare cases, however, the converse is true, and 
the treatment to be immediately adopted is to send the patient back 
to the region in which he has enjoyed immunity from attack. Where 
the disease has originated in a damp climate, the patient should be 
sent to a dry one, and if at the seashore, an inland spot should be 
selected in the same empiric way. If asthma be contracted in a low- 



ASTHMA. 57 

lying or cold situation, the physician may be led to advise his removal 
to an elevated or warm atmosphere. 

The diet should be most carefully regulated and excess avoided. 
Animal food should be sparingly used. Some patients may be cured 
by a purely vegetarian regimen. 

Food should be taken at regular intervals, and the boa-constrictor 
plan of one enormous meal in the evening of the day must be given 
up. As a rule, liquids should be sparingly used and stimulants re- 
stricted, especially malt liquors. Now and then cases may be rarely 
met with in which excess of starch or vegetables cause aggravation of 
symptoms — a free fish diet will then be indicated. The bowels must 
never be allowed to get constipated. 

In hereditary cases prolonged gymnastic exercise, and, as far as pos- 
sible, everything effecting a change in the patient's environment, must 
be thought of. 

Where the affection is depending upon bronchial inflammation, the 
judicious treatment of this by expectorant remedies will be the obvious 
preventive measure. Where Bright's disease, joint troubles of a 
rheumatic kind, gout, and skin diseases, and morbid states of the blood, 
caused by a deficient elimination of excrementitious products by the 
emunctories, are the cause of the attacks, much may be done to pre- 
vent their recurrence by attention to these morbid conditions. 

In some cases the presence of asthma has been found to depend 
upon nasal polypi, or hypertrophy of the turbinated bones, the parox- 
ysms never returning after the removal of the local trouble. Though 
this cannot be a common cause, the physician should be upon the 
watch for it, and if there be obstruction or irritation in the nostril, it 
had better be removed. 

The remedies used in the treatment of the attacks are legion, and, 
unfortunately, the physician is driven to try one drug after another ; 
the means which afford speedy relief to one patient may aggravate the 
paroxysm in the next ; nevertheless, there are certain remedies about 
whose general value there is little room for doubt. 

Inhalations. — The urgent distress of the paroxysm calls for a 
remedy which will be quick in its action ; hence those which directly 
reach the bronchial surface are indicated. The oldest, and perhaps the 
most prized, of this class of medicines is the nitre paper, made by soak- 
ing thick blotting paper in a warm solution of 2 ounces of nitrate of 
potash in a tumblerful jf water. After drying, this paper should be 
burned rapidly and in large quantity in the apartment of the patient, 
and, as the suffocating air of the room becomes unbearable to his 
attendants with the nitrous fumes and smoke, the asthmatic begins to 
breathe with ease and comfort. It is a common mistake to burn too 
little of the paper, and to have the solution too dilute. Huggins's 
ozone paper is prepared by adding iodide of potassium to the nitre 
solution, and chlorate may be also added, as suggested by Thorowgood, 
to increase the activity of the combustion. 

5 



58 ASTHMA. 

Stramonium and various drugs of the same class are burned in a 
somewhat similar way, this being the basis of most of the patent 
asthma cures, as Himrod's, Girdwood's, Senier's, and others. . The 
formula recommended by Sir J. Sawyer answers well. It is made by 
mixing together 2 ounces of coarsely powdered stramonium leaves with 
1 ounce of powdered anise fruit and 1 ounce of powdered nitrate of 
potash. A little of this placed upon a plate and ignited with a match 
gives off dense fumes, which generally afford prompt relief. Mullein 
{verbascum thapsis) is sometimes added, and a minute quantity of arsenic 
is a valuable addition, and powdered tea enters into most of the good 
asthma powders ; tobacco, also, is sometimes added. 

The inhalation of pyridine is often of great value ; it is one of the 
products formed during the combustion of the stramonium powder. 
A teaspoonful poured upon a plate soon permeates the air of the apart- 
ment with an intensely disagreeable and penetrating odor. It is highly 
recommended by See, but patients soon turn against its unpleasant and 
nauseating smell. 

Instead of burning stramonium and inhaling the fumes, it is a 
common practice to smoke it in a pipe, and there is no doubt that in 
this way many asthmatics get relief. A little nitre may be added to 
the chopped leaves, and belladonna is sometimes mixed with them. 

Datura tatula, a drug of the same order, is often more satisfac- 
tory, and its action is very decided. The writer has never known a 
case of asthma in which it has been used without giving some relief, 
and often very prompt and complete relief. It is smoked like the stra- 
monium. Both these drugs can be obtained in the cigarette form, and 
when arsenic is added, a very valuable remedy is obtained, which gen- 
ally gives more than mere temporary relief. This is the composition 
of the cigarettes of Le Vasseur and Discorides ; i grain of arsenite of 
potassium is enough for each. 

Lobelia is sometimes mixed with the stramonium before smoking. 
It enters into the cigarettes made by Espie and Joy, which also con- 
tain stramonium. 

Opium is occasionally useful. In very bad attacks, where the 
patient cannot swallow, and where he can only inhale with great diffi- 
culty, the best treatment is to give hypodermically I to 1 grain of 
morphia, with -^ grain of atropia. This combination often acts very 
rapidly. A morphine suppository often answers all indications, but it 
is slow. 

Dieulafoy, at the beginning of an attack, paints the nostrils as high 
up as possible with a 5 per cent, cocaine solution, and sprays this over 
the mouth, throat, and nose for a few minutes, and if the attack does 
not speedily yield, he injects the drug hypodermically. 

Nitrite of amyl is sometimes of great value in relieving the 
spasm, and it may be employed in the form of capsules (5 minims 
each). The vapor acts often very promptly, but its effect is exceed- 
ingly evanescent. (See its internal administration upon page 43.) 



ASTHMA. 59 

Chloroform vapor is a favorite remedy with some. Its actiou 
seldom mils, but it is not a remedy to be often repeated, and may prove 
fatal where there are cardiac complications. Ether, though safer, is 
more disagreeable, slower, and less certain to give relief. 

Iodide of ethyl is strongly recommended by Thorowgood, who 
advises the inhalation of the vapor of 10 minims three or four times 
a day. It can be had in glass capsules like amyl nitrite, and, in addi- 
tion to its antispasmodic power, it is a valuable expectorant. Martin- 
dale's capsules, each containing 10 minims of chloroform and 5 of 
iodide of ethyl, are very safe and effectual, and are highly recom- 
mended by Williams as being capable of safe administration by the 
patient or by nurses ; they relieve the spasm and quiet the cough which 
accompanies it. The iodine exerts its influence upon the system long 
after its inhalation, and alteration in the character of the sputum soon 
is noticed. 

Ipecacuanha wine, in the form of fine spray, is of value in asthma 
where there is much bronchial inflammation. 

Steam inhalation alone, or mixed with terebene or menthol, or' 
oil of eucalyptus, cajuput, creasote, or Friar's balsam, is sometimes 
very soothing and grateful. 

When the patient can swallow, a large dose, say 30 grains of chloral, 
will cut short the attack if given at its very commencement, and Will- 
iams strongly recommends this drug to be taken at bed-time, or even 
every four hours, for several days if bad spasms are threatening. 

Williams's plan is to give the strammonium, belladonna, or hyos- 
cyamus in the form of succiis or tincture, combined with the iodide of 
potassium, to be taken during the day, and to administer a pill of ex- 
tract of belladonna or of stramonium (i grain) during the night attacks. 
The following is an excellent combination : 



R . — Potassii iodidi . 
Liq. Fowleri 
Villi ipecac. 
Tinct. hyoscyam. 
Aquse camphorse 

— Take a tablespoonful three times a day, in water, after 



£ij- 

3iv. 
giv. 
gviij. M. 

meals. 



Iodide of potassium holds the first place amongst drugs for in- 
ternal administration in asthma. It may be given in small doses three 
or four times a day after an attack as a preventive of further ones, or 
it may be given in doses of 5 or 8 grains every four hours in the face 
of an expected paroxysm. Along with it any of the inhalations pre- 
viously mentioned may be employed in the presence of a severe 
paroxysm. 

Stramonium or belladonna in the form of extract, in doses of 
about e grain, may be given with each dose of the iodide, or i grain 



60 ASTHMA. 

of either extract may be given at bed-time, or a few hours before the 
expected attack. 

Lobelia is much praised in asthma, but the writer has, through 
giving only small doses, generally failed with it. It is, moreover, a 
serious depressant to the heart in large doses. Teaspoonful doses of the 
ethereal tincture (1 in 8) may be tried every four hours. It will give 
relief if the physician have courage to push it. 

Nunes has found that lobeline— the alkaloid from lobelia — may be 
given by the mouth in doses of 1 to 4 or 5 grains without producing 
the nausea or depression caused by the ethereal tincture, which owes 
its objectionable properties to another emetic principle.- Excellent re- 
sults are reported from its use. 

Arsenic is a medicine of great value in the treatment of asthma. 
Reference has already been made to it when administered in the form 
of cigarette, or when mixed in minute quantity with the stramonium 
for burning. It is given internally with equal benefit in small doses, 
and may be combined to great advantage with the iodide of potassium. 
It is often advisable after profuse expectoration to give iron to combat 
the weakness and ansemia resulting from the drain upon the system. 
In these cases the iron may be combined with arsenic. 

Mount Dore and Bourboulle waters owe their great value in 
asthma to the amount of arsenic in their composition. 

Nitrites of soda and potash are serviceable in asthma, and if 
given in small and often repeated doses will prevent paroxysms in those 
cases associated with high tension. 

Nitro-gycerin will give good results in these cases, and if admin- 
istered in the minute doses overy hour, as described upon page 45, 
excellent effects will be secured. 

Apomorphine in doses of yg- grain, whera there is much bronchial 
irritation, may be tried, and y 1 -^ grain hypodermically will sometimes 
cut short the paroxysm when internal remedies fail. 

Antipyrine in full doses, 30 grains, has been given with great 
success at the beginning of an attack, and in small doses, 10 grains, 
three times daily between the attacks ; it prevents their occurrence or 
lessens their severity. 

Caffeine in doses of 1 to 3 or 5 grains has been productive of good 
in the treatment of asthma. Where there is cardiac failure, it is a very 
safe and efficacious drug, and much more satisfactory than digitalis and 
spartein. It can be well given in strong coffee or tea. 

Alum sometimes relieves spasm of a severe nature, and it is recom- 
mended to give 10 to 15 grains dry by placing it upon the tongue. In 
full doses it is liable to excite nausea. 

Chloral will generally give relief, and is much thought of by some 
physicians. Its treacherous action upon the heart is a serious draw- 
back, and there is the danger of patients becoming enslaved by its 
habitual use. As already stated, it may be used to cut short a 



ATHETOSIS. 61 

paroxysm if given as soon as the premonitory symptoms show the 
approach of an attack. 

Gelsemtum, grindelia, and euphorbium pilulifera have been 
tried and found successful in some cases ; the two last may be given 
every four or six hours in doses of 1 grain to the pilular extract ; 10 
minims of the tincture of gelsemium may be administered four times 
a day. 

Oxygen or compressed air, in inhalation, have their advocates. 

Hyoscine, hypodermically, in doses of 1 to 2 minims of 0.5 per cent, 
solution, will cut short the paroxysms, and 

Morphine, hypodermically, or cannabis indica, by the mouth, 
act in the same way ; and pilocarpine, subcutaneously, has its advo- 
cates ; but this latter drug acts best where there is no secretion, while 
hyoscine and belladonna or atropine are indicated when there is much 
secretion. 

Quebracho, in doses of 15 minims of the liquid extract, or of ^ 
grain of the commercial alkaloids, known as aspidospermine, has 
been used with success in the treatment of asthma in America. It has 
a powerful sedative effect upon the respiratory centre, and is indicated 
where there is much cardiac failure. 

Strychnine has proved useful where there is exhaustion of the 
respiratory centre. Its use is, however, seldom indicated, and it may 
increase the distress. It has been recommended by Mayo, who gives 
it hypodermically with atropine. 

Quinine is open to the same objection. 

Bromide of potassium may do some good by relieving spasm, but 
its action is too slow to be of much value. 

Tobacco will give marked relief (acting like stramonium when 
smoked), but only to those who are strangers to its habitual use. 

Blistering over the pneumogastrics with cantharides or strong iodine 
liniment may be tried in conjunction with any of the above treatments, 
and galvanism (continuous or induced current) applied cautiously to 
the same region has been advocated. 

Antispasmodics, like asafcetida or ammoniacum, and the entire range 
of expectorants from antimony to sulphur, have been tried with very 
varying success. 

ASTHMA, CARDIAC. 

This will be relieved by the judicious use of the various drugs men- 
tioned under Heart Diseases. 

ATHETOSIS. 

The slow, irregular, deliberate movements generally seen in the arm 
or leg, and constituting the diseased condition known as athetosis, is 
not beyond the reach of treatment. Gowers has had marked success 
by the use of the continuous current, by placing the positive pole upon 



62 BALANITIS 

the spine or brachial plexus, and the negative pole upon the affected 
muscles, and persistingly persevering for months. At the same time 
arsenic in moderate doses is given by the mouth, and sedatives like 
conium or morphine or Indian hemp may be given as indicated. 
Bromide of sodium, in daily doses of not less than 90 or 100 grains, 
should have a fair trial. It may be given in the following combina- 
tion : 



R. — Sodii broniidi .... 
Liq. Fowleri .... 
Tinct. conii . . 
Aquae camphorse 
S.— Take a tablespoonful three times a day 

BALANITIS. 



. ad gx. — M. 

after meals, in a little water. 



Where this condition comes on in young subjects with long prepuce, 
as the result of retained secretion, drawing back of the foreskin and 
thorough cleansing of all discharge several times daily, dusting the 
part with a powder consisting of equal parts of carbonate of zinc, boric 
acid, and powdered starch soon effect a cure. When the disease is very 
chronic or is apt to return, circumcision should be performed, especially 
if phimosis be present. 

Should the inflammation have lasted long enough to produce ex- 
coriations of the membrane living the prepuce or of the surface of the 
glans, they should be touched lightly with nitrate of silver, nitric acid, 
carbolic acid, or liquor hydrarg. nit., and covered with a piece of dry lint 
inserted between the glans and foreskin. Where the prepuce cannot 
be drawn backward, a fine syringe should be used frequently to inject 
a stream of tepid water, colored with Condy's fluid, between the opposed 
mucous surfaces. Afterward a weak corrosive sublimate solution (1 : 
1000), or nitrate of silver (1 : 100), or yellow wash, may be injected. 
If the foreskin can be drawn back, any of these applications may be 
inserted upon lint and left in situ. 

Where the balanitis is part of a gonorrhoea, rarely will it be neces- 
sary to do anything but inject permanganate of potassium (1 grain to 
2 ounces) round the glans and also down the urethra, curing both com- 
plaints at the same time. If there be much pain and redness, a lead 
and opium lotion applied outside on lint gives relief. Acupuncture is 
generally bad practice. Should there be a chancre or sore or ulcer 
causing hemorrhage, one free cut, slitting up the prepuce on its dorsal 
aspect, should be made, and lime-water, sulphate of zinc (1 : 100), 
boric acic (1 : 50), or carbolized oil (1 : 15), may be used as a dressing ; 
or oleate of zinc or boric ointment may be applied. 

The writer has permanently cured many cases by dilating the 
prepuce with phimosis-forceps or dressing-forceps after the irritation 



BALDNESS. 63 

subsided, even where the orifice hardly admitted a thick probe, and 
this, too, in adults. 

BALDNESS. 

For the thinning of the hair, beginning at the vertex and gradually 
progressing toward the forehead, or beginning in the frontal region 
and extending backward, much difficulty will be found in checking its 
progress. If there be any diseased condition of the scalp, as seborrhoea 
sicca or pityriasis, by the liberal use of animal or vegetable fats the 
progress of the affection may be effectually stayed. If the baldness be 
due to senile change, treatment is useless. In ordinary cases, where 
the health is good and where there is nothing to give a clue to the 
cause of the baldness, the treatment will consist of local stimulation to 
the atrophied hair-bulbs. 

The best remedy is galvanism. A slow, continuous current passed 
through the scalp by brush electrodes has a powerful influence over 
the nutrition of the hair-bulbs in their early stage of atrophy. Shaving, 
shampooing, or blistering the scalp may be tried, but the most conve- 
nient and effectual plan is by the application of irritants or stimulants 
in such proportion that actual vesication is avoided, and a chronic con- 
gestion or erythema is habitually kept up. 

Foremost among remedies of this class comes cantharides, which 
may be combined with other local stimulants, thus: 

B . — Tinct. cantharidis . . . . . . . 5 iv. 

Olei rosmarini . . . . c . gij, 

Spt. carnphorse . |; j. 

Olei ricini ^vj. — M. 

The writer has found the following the best combination : 



Be . — Olei rosmarini 

Liniment, canthar. 
Olei amygdal. dulc. 
Spt. camphorse 
Glycerini (purif.) . 
Otto de rosse . 
Pilocarpine hydr. . 

—To be well rubbed into the roots of the hair mor 



. 3iv. 

. giv. 

• gij: 

• liij- 

• 3J. 

. gtt. viij. 

. gr. v.— M. 

ning and night. 



Gull's linimentum myristicse (1 part of expressed oil of nutmeg to 3 
of olive oil) is a safe and mild stimulant. 

Innumerable drugs have been from time to time praised as specifics 
— paraffin oil is, perhaps, one of the best. The writer has seen the 
following pomade produce good effects; he has devised this formula 
after many trials. It may be tried where lotions cannot be used : 



64 BALDNESS. 

R . — Pilocarpin. hydrochlor. . . . .. . gr. xx. 

Aquse destillatse - gij. 

Fiat solutio et adde 

Lanolini puriss. . . . . . . g x. 

Olei petrolei ("snowflake") gvj. 

Olei bergamot. . . . . . . . gss. 

Olei verbenas. . . '.. . . . . gss. — M. 

Jaborandi and pilocarpine appear to possess some influence over the 
nutrition of the hair, and they have been even administered with this 
intention, and given hypodermically, but the results are doubtful. 
Arsenic certainly has some effect upon the hair when administered 
internally. 

Ammonia is a good stimulant, and may be applied with cantharides. 

R. — 01. amygdal. dulc. §ij. 

Aquas ammonias . . . . . . . ^ij. 

Tinct. cantharidis . . ... . \ ' jf ss. 

Spt. myristicas . . ! . . . . ^j. — M. 

Capsicum, mustard, euphorbium, and strong acids have been used, but 
their application is not to be advised. The volatile oil of mustard, if 
very well diluted, is of some value. 

R. — Olei sinapis volat. . . . . . £ij. 

Olei petrolei ^j. 

Olei olivas . . . . . . . § ix. — M. 

For syphilitic baldness, in addition to the usual constitutional treat- 
ment, a pomade made by adding 2 drachms of white precipitate to 
4 ounces of marrow is of value. 

Upon the supposed parasitic nature of some cases of common bald- 
ness all sorts of germicides have been used. They can only be of use 
when applied in such strengths as to cause irritation. Sulphur oint- 
ment has been recommended. It is a most disagreeable application. 

Baldness due to alopecia areata is believed by a few to be parasitic, 
and is treated by them with remedies such as are used for ringworm, as 
chrysophanic ointment, corrosive sublimate (1 : 200), carbolic acid, sul- 
phur, or iodide of sulphur ointments. It appears that these applica- 
tions do good, but probably by their local stimulating action. 

The strong solution of the nitrate of mercury, lightly brushed over 
the spot, is often followed by speedy changes in its appearance, and the 
writer, though not believing in the parasitic nature of the affection, has 
seen better results from painting over the patches with strong sulphurous 
acid than from any other treatment, save constant blistering with can- 
tharides. After a time, if there be no signs of the growth of hair 
upon the bare patch, the blistering should be stopped, and the milder 



BED-SORES. 65 

stimulating compounds previously mentioned may be applied. Some 
authorities lay great stress upon food supposed to stimulate the nutrition 
of the nerves, as fats, phosphates, crushed wheat, and fish ; and with 
the erroneous idea that such substances as Parrish's syrup and other 
phosphates can supply free phosphorus, others recommend these drugs 
internally. Phosphorus, arsenic, strychnine, pilocarpine, and cod-liver 
oil are advocated. 

BED-SORES. 

Bed-sores may be prevented in the majority of instances by careful 
nursing and great cleanliness. Where they may be expected, as in 
tedious fevers, paralysis, and bladder cases, all pressure must be avoided 
over the prominences of the sacrum and trochanters by the use of 
water beds and air cushions, avoiding feather beds and under-blankets 
and mackintoshes as far as possible, depending upon prompt and fre- 
quent changes of smooth linen draw-sheets. 

The skin should be well cleansed with Pears's soap and water, and 
after drying with a sponge or soft cloth, it should be dabbled over with 
eau de cologne, or camphorated spirit, or a solution of 30 grains of 
corrosive sublimate in 1 pint of spirit, and dried, after which finely- 
powdered Fuller's earth, zinc oxide, or zinc carbonate may be dusted 
over it. If there be a tendency to dryness of the skin, a little lanolin 
may be rubbed in instead of the powder. If redness has already 
become permanently established, painting over the spot with flexible 
collodion may ward off the threatening abrasion. If this has, however, 
already occurred, a piece of soap plaster, gently warmed, should be 
placed over the spot, and the use of wet applications stopped. An 
ointment composed of 30 grains of finely-powdered camphor and 1 ounce 
of zinc ointment is safe treatment at this stage, and may prevent the 
abrasion becoming an ulcer. 

If sloughing has already taken place the application of poultices of 
linseed should be continued only until the slough separates. It is a 
sad mistake to apply these poultices when too hot, thereby lowering 
the vitality of the surrounding skin, and between the application oi 
each the sore should be syringed or douched with lotions of alum, 
(1 : 100), chlorate of potash (1:100), carbolic acid (1:40). Should 
there be much fetor, solution of corrosive sublimate (1 : 200) may be 
used, or the slough may be dusted over with powdered boric acid. 

After the separation of the dead matter, and when the sore is made 
clean and sweet, it is to be treated as an ulcer by applications of any 
of the previously mentioned lotions applied upon lint, covered over 
with oiled silk, held in place by strips of soap plaster. The best lotion 
in the majority of cases is spirit lotion (1:2). 

The continual moisture of the lotion, in many instances, will cause 
some irritation of the healthy skin under the oiled silk, and in these 
cases an ointment is better. The favorite is a pomade made by mix- 
ing 2 ounces of Basilicon ointment with 2 ounces of balsam of Peru. 



ACUTE INFLAMMATION OF. 

Boric, carbolic, or salicylic ointments, may be used, or calamine, 
zinc oxide, or iodoform may be applied as an ointment or dusted over 
the sore in fine powder. 

Bird's plan of healing ulcerated bed-sores in paralysis is very highly 
spoken of by those who have used it. He places a thin plate of 
metallic silver over the ulcer, its margins just covering over the mar- 
gins of the raw surface and not projecting to any extent upon the 
sound skin ; to the silver is attached a wire six or eight inches long, 
which is attached by its other extremity by a small disc of zinc, which 
is separated from the skin over which it lies by a piece of wash-leather 
soaked in vinegar. Healing is very rapid under the galvanic action 
thus set up. 

Under the article on ulcer will be found a list of the various appli- 
cations which may be used for the healing of the sore if the above 
fail. While the healing process is going on it will be advisable, and 
in some cases absolutely necessary, to remove all pressure from the 
sore ; the various air and water cushions will generally prove useless. 
The best plan will be for the physician to direct the nurse to make a 
small cushion out of soft, old linen or calico, and stuff it with sheep's 
wool carefully teased out. This appliance can be shaped to the irreg- 
ularities of the part, with a circular opening in the centre opposite to 
the bed-sore. 

BLADDER, Acute Inflammation of. 

The treatment of this affection will depend upon the cause. Thus 
if the cystitis be the result of an extension backward of a gonorrhoea 
— a common cause — absolute rest in bed and warmth, hot baths or hot 
hip baths (t. 105°) frequently repeated, and a suppository of I grain of 
morphia or i grain of green extract of belladonna should be given to 
allay pain and spasm. 

Stimulants and solid food must be stopped, and coffee and tea for- 
bidden. The diet, while the acute stage lasts, should be entirely milk, 
or milk diluted with barley water, and kali water, iced, if the patient 
can take it. A large linseed poultice covering the lower part of the 
abdomen gives relief. 

Hyoscyamus, in doses of 20 to 40 minims of the tincture, should be 
given every four or six hours, according to urgency. 

Opium may be combined with it in doses of 15 minims of the tinc- 
ture. This may be given in infusion of linseed freshly prepared, to 
each small cup of which from 20 to 30 minims of liquor potassse is 
added. There need generally be no fear of increasing the pain by 
taking moderate amount of diluent drinks. Injections for the gonor- 
rhoea should be stopped, and not resumed until urgent symptoms sub- 
side, then weak, warm injection of water, colored with Condy's fluid, 
may be commenced, gradually and cautiously increasing the strength 
until 1 grain of permanganate to each ounce can be painlessly used. 



CHRONIC INFLAMMATION OF. 67 

Where the acute cystitis is the result of an attack of gout, smart 
saline purges, followed by colchicum and large doses of bicarbonate of 
potash, are indicated. 

The attack sometimes follows the application of a blister to some 
part of the body, and, when the first signs of cystitis supervene, the 
blister should be instantly removed and a large warm poultice applied 
over its site, 40 minims of laudanum per rectum given. Hyoscyainus 
internally, and hot hip-baths and diluent drinks soon relieve all trouble 
in a few hours. (See under Strangury.) 

When the attack follows irritation from injury or stone, the removal 
of the exciting cause, after relieving pain by the above treatment, 
should be attempted. (See Stone in the Bladder.) 

BLADDER, Chronic Inflammation of. 

The cause, if possible, should be determined and treated. The causes 
are : (1) Atony of the bladder, permitting a quantity of urine always 
to remain behind after micturition, (2) calculus, (3) tumor, (4) stric- 
ture, (5) enlarged prostrate, (6) paralysis affecting the spinal centre, 
(7) uterine affections, (8) gout, etc. 

In those cases where the immediate removal of the cause is not pos- 
sible, the first indication is the sympathetic use of the catheter. This 
is imperative, as pain and frequency of micturition will not disappear 
until the complete evacuation of the contents of the bladder. The 
intervals between the use of the catheter are to be gradually length- 
ened, until morning and evening catheterization be sufficient. As a 
rule, very considerable relief will attend the removal of all the urine 
contained in the bladder, and the catheter need not be again used 
until slight symptoms of distress are felt. After the attack of cystitis 
seems to be passing off, as the urine gets clear the catheterization may 
be suspended. If enlargement of the prostrate or central nerve lesion 
be the cause, the habitual use of the catheter will probably last dur- 
ing the patient's life time. Soft India-rubber instruments should be 
used, and, as a rule, oil should not be employed for their constant 
lubrication, as its action upon the rubber is such as to make the in- 
strument brittle and liable to break off in the bladder or passage. 
There is nothing so good as a lubricant as the glycerin boracis (B.P., 
1867) ; it is a good antiseptic, and sterilizes the instrument each time 
— a matter of vital importance. 

Occasionally, but not often, it may be necessary to tie in a catheter, 
and then only a rubber one should be used. 

Injections into the bladder after washing out the organ are in favor 
with most surgeons, and many substances are used for this purpose, 
and several instruments are recommended. The best, and one that 
answers every requirement, is a couple of feet of India-rubber tubing, 
such as is used for children's feeding bottles, attached at one end to a 
small glass funnel, at the other by means of a bit of fine glass tubing 
it is connected with a large-sized rubber catheter. Upon the patient 



68 BLADDER, CHRONIC INFLAMMATION OF. 

lying down and inserting the catheter in the bladder he draws off the 
urine, and by elevating the funnel and pouring in a few ounces of 
tepid water it finds its way into the bladder, after which depression of 
the funnel permits it to flow out again, and thus every particle of 
mucus can be washed off the coats of the viscus. Any of the follow- 
ing solutions can then be poured in, and the bladder thoroughly washed 
out with them, only permitting 2 to 4 ounces to remain in at once. 
They should not be used if there be much pain or tenderness : 

Boric acid, 1 to 2 drachms ; water, 10 ounces. 

Borax, 2 drachms ; water, 10 ounces. 

Carbolic acid, 1 drachm ; water, 10 ounces. 

Nitric acid, as much as will make water pleasantly acidulous to the 
mouth. 

Quinine, 15 grains; dilute nitric acid, 20 minims; water, 10 ounces. 

Nitrate of silver, 3 grains; water, 10 ounces. 

Sulphate of copper, 5 grains ; water, 10 ounces. 

Sulphate of zinc, 5 grains ; water, 10 ounces. 

Permanganate of potassium, 3 grains ; water, 10 ounces. 

Resorcin, 1 drachm; water, 10 ounces. 

Chloral hydrate, 10 grains ; water, 10 ounces. 

Pure castor oil, gently warmed. 

Creolin, 1 drachm ; water, 10 ounces. 

Pure, fresh, healthy urine. 

Of these, boric acid is unquestionably the least irritating, and though 
its iuternal administration renders washing out of the bladder seldom 
necessary, still it may be occasionally used with freedom, and a quart 
of the solution may be used at one sitting in small quantities at a 
time. 

A large number of drugs possess considerable power over the blad- 
der and urinary secretion as they pass out after being administered by 
the mouth, and much benefit may be obtained by their administration 
in chronic cystitis. 

By far the most valuable of these is boric acid, and there are few 
more surprising results in the therapeutics than is to be seen after a 
few doses of this drug. Urine, which is passed ammoniacal and so 
highly offensive as to polute the air of the sick room, may, in forty- 
eight hours or less, be voided clear and free from every trace of smell 
after 15 grains of the acid three or four times a day in a glass of water 
or milk. 

The administration of this drug will, in the great majority of in- 
stances, enable the surgeon to dispense with washing out and injecting 
solutions into the bladder. After some days the dose may be dimin- 
ished to 5 grains three times daily. The only objection to its admin- 
istration rests in its liability to irritate the stomach and destroy the 
appetite. This is less likely to occur if it be largely diluted, and the 
writer dilutes 10 grains with a half pint of kali water or with one 



CHRONIC INFLAMMATION OF. 69 

pint of milk ; under these precautions it may be taken for many 
months without inconvenience. 

Bucliu, in doses of a large wineglassful (3 to 5 ounces) of the infu- 
sion three or four times a day, is indicated in recent or acute cases ; 
if improvement does not soon follow, its use may be suspended, and 

Triticum repens, made into a decoction by boiling 4 ounces of the 
fresh rhizome in one quart of water and taking the entire quantity 
during the twenty-four hours, may be followed by marked improve- 
ment. 

Sir H. Thompson advises, in chronic cases with much mucus and 
alkaline urine, either the infusion of 

Alchemilla arvensis, 2 drachms in 5 ounces of water, three times a 
day ; or, 

Uva ursi, in doses of a wineglassful of the infusion ; or, 

Pareira brava, in doses of a wineglassful of the decoction three or 
four times a day. 

Any of these vegetable remedies can be most effectually combined 
with 5 grain doses of boric acid. 

Zea mays (drachm doses of the liquid extract) is a drug of much 
value. 

Alkalies, as bicarbonate of potash or the liquor potassse, are of great 
value in cystitis, and may be given in combination with any of the 
above, or with hyoscyamus. 

Benzoic acid, in doses of 10 to 20 grains, in passing out as hippuric 
acid, acts as an antiseptic, and also diminishes the alkalinity of the 
urine. Its various salts may be administered in the same way. 

Mineral acids have scarcely any appreciable power in diminishing 
the alkalinity of the urine in cystitis, and their administration with 
this intention generally ends in disappointment. 

Hyoscyamus is a remedy of great value for the relief of pain in 
cystitis. (See under Acute Cystitis.) 

Belladonna, chiefly in the form of suppository, has been before re- 
ferred to, as has also been morphia. Belladonna, in small doses by 
the mouth, is often successful in mild chytitis in children. 

The diet and general care of the patient should be upon the same 
lines as indicated for acute cystitis: Change to a warmer and drier 
climate, with the use of natural alkaline water like Vichy or Vals, or 
the sulphur waters of Bonnes or Harrogate, may do much to restore 
the patient. Avoidance of stimulants, exposure to cold and wet, and 
fatigue of body, especially long carriage or omnibus drives, must be 
carefully guarded against. The catheter is to be used to ensure com- 
plete evacuation. 

Cantharides, turpentine, eucalyptus, santal, copaiba, and cubebs are 
often administered, but their effects are uncertain and so often followed 
by renal irritation that they should be administered with great caution. 



70 BLADDEK, ATONY OF — BOILS. 

BLADDER, Atony or Atrophy of. 

The treatment of this affection in its early stages will generally mean 
the removal of the obstruction to the flow which has caused the dis- 
tension and wasting of the muscular coats. In the later stages the 
treatment will be that indicated for chronic cystitis. The habit of 
retaining the urine for too long a period must be abolished, stricture of 
the urethra must be dilated, and accumulation of the feces in the 
rectum should be cleared out. Tumors, calculi, or enlarged prostate 
will require attention, and those spinal lesions (sometimes caused by 
injury) or cerebral affections which lead to retentions will require 
appropriate treatment. 

Drugs are of little value in improving the tone of the bladder 
muscle, but some improvement may be obtained by general hygienic 
measures and full doses of strychnine and iron, or Easton's syrup, ergot, 
or minute doses of cantharides. The constant current is of undoubted 
value; but judicious catheterization, with clean rubber instruments 
and the administration of remedies to keep the urine normal, as 
enumerated under the treatment of chronic cystitis, will make catheter 
life tolerably comfortable. 

Dr. Wales had obtained excellent results from 2 ounce doses of the 
infusion of golden rod (solidago virgaurea), 1 to 20, every four hours. 

BLEPHARITIS OR TINEA TARSI. 

The first object is to remove the minute scabs or crusts before apply- 
ing any remedy. This can only be done by carefully bathing the eye- 
lids with a warm alkaline lotion (2 drachms of bicarbonate of soda to 
1 pint of water) for half an hour till the crusts come easily away, after 
which the margin of the lid is carefully dried, and an ointment of the 
yellow oxide of mercury (10 grains to 1 ounce of vaseline) freely 
smeared over it. This treatment must be carried out twice a day at 
least, and must be persevered with for weeks till every trace of the 
disease disappears. Should it fail, which is seldom, unless through 
carelessness, the edge of the lid should be painted with strong solution 
of nitrate of silver (1 drachm to 1 ounce), and the ointment continued. 
Should there be much inflammatory symptoms, epilation is of great 
value, and recent cases may be speedily cured by removing the hairs 
and applying the mercurial ointment just mentioned. The disease 
often occurs in the ansemic and strumous, and sometimes local remedies 
are of no avail, unless after a prolonged course of iron, combined with 
cod liver oil, extra feeding, pure air, and a change to the seaside. 

BOILS. 

The patient should have careful attention to general health — a gen- 
erous, plain, unstimulating diet, without alcohol or wine in the early 
stages. There is nothing influences the growth of boils, in the writer's 
opinion, like a diet into which onions largely enter. The Spanish onion 



BOILS. 71 

boiled till tender in an open vessel, may be eaten ad lib. at supper or 
breakfast, or at both times. The gentle purgation following is also an 
advantage. Some benefit has been reported to follow dose of y 1 ^ grain 
of sulphide of calcium as a prophylactic in the early stages, or to assist 
maturation at a later period. There is, however, little evidence to show 
that it behaves in this paradoxical way. Sulphur waters (Bonnes, 
Harrogate, etc.) may be given with benefit. Yeast, in doses of a 
tablespoonful of the fluid form, three or four times a day before meals, 
is affirmed to be efficacious in preventing boils when threatening. 

Flour (wheaten) in tablespoonful doses, mixed up in cold water, is 
stated to effectually prevent the development of boils. 

Quinine, in doses falling short of cinchonism, is also used, and iron, 
to the point of saturation of the system, has its believers. 

Upon first appearance of a boil, it is worth while to scrape the skin 
over it with a sharp scalpel till a drop of blood appears, or pluck out 
the hair growing in the inflamed follicle, as it is said these means may 
often prevent suppuration. The spot should then be brushed over 
with (1) the strong solution of the acid nitrate of mercury, or (2) col- 
lodion, or (3) strong solution of nitrate of silver (1 drachm to 1 ounce). 
Sometimes one or other of these remedies causes abortion of the boil, 
but their effects are very uncertain. It is better to either cover the 
boil at this stage with a little extract of belladonna rubbed down with 
glycerin, or to apply a small piece of belladonna and opium plaster or 
galbanum and opium plaster, in the centre of which a hole may be cut 
when the boil points. Should there be much pain or throbbing, a good 
linseed poultice, smeared over with boric acid ointment, should be 
applied. Wet applications covered with oiled silk should be avoided 
owing to the danger of crops of small boils appearing where the silk 
is in contact with the healthy skin. For the same reason it is very 
important that the poultice should not be covered with mackintosh or 
gutta-percha tissue. 

Sometimes strapping the boil with strips of plaster affords relief, at 
other times it occasions great pain. An incision should be made if the 
tension cause constitutional disturbance ; one moderately free wound 
will do good ; the crucial incision is needless. Pain may be somewhat 
relieved by the application of cocaine, and the pain of the incision 
may hardly be felt if strong carbolic acid be previously painted over 
the boil. 

The application of a poultice to clean the sore at this stage assists 
matters, and the boil may now be dressed with any antiseptic ointment 
ar lotion, the former being preferable. 

The early incision and the sparing use of poultices have certainly an 
influence in retarding the progress of successive crops of boils. 

The injection of carbolic acid into boils in their early stage is 
painful and not free from danger. A 5 or 3 per cent, solution injected 
into the centre of the boil can do little harm and may stop the sup- 
puration. 



72 bright's disease, acute. 

During the suppurative stage, if many boils be present, the diet may 
be enriched, stimulants and strong soups may be given, and change of 
air may be advisable. 

Iron and arsenic are now useful, or iron and chlorate of potash 
may be freely administered. Sulphites and phosphate of soda have 
their advocates. Saline purgatives and sulphur waters may be given 
at a later stage. 

Boils in the ear are exceedingly troublesome and very painful. 
Grosch has found that a solution of acetate of alumina (1 : 4 of water) 
causes the speedy abortion of furuncles in the external auditory canal. 
The Avriter has had great satisfaction with the B. B. solution of cor- 
rosive sublimate dropped into the ear twice a day; after its instillation 
cotton wool soaked in it should be left in the canal. This treatment 
will effectually prevent the return of the affection. Boric acid may be 
insufflated, or a strong alcoholic solution instilled. 

BONE, Diseases of — See Caries, Periostitis, etc. 

BREAST, Cancer of— See Cancer. 

BREAST, Abscess of, and Inflammation of— See Mammary- 
Gland. 

BRIGHT'S DISEASE, Acute. 

In acute Bright's disease the patient should be at once placed in bed 
between blankets, and enveloped in a sleeping suit of light flannel. 
The diet should consist entirely of milk, stimulants in every form, 
animal food, and eggs being at first rigidly prohibited. After the very 
acute symptoms pass off, any farinaceous food may be allowed. The 
chief indications for treatment are to act upon the skin, bowels, and 
kidneys, so as to cause elimination of the products hurtful to the 
economy. Sometimes the indications may be limited to the removal of 
these products by the skin and bowels alone, if the kidneys be in a 
condition in which their functions are for the time in suspension. 

Diaphoretics. — Drachm doses of the liq. ammon. acetatis, with 20 
minims of spt. aether, nit., is a harmless and often efficient way in which 
to start the action of the skin in mild cases. Should there be feverish- 
ness present, 1 minim of the tr. aconiti may be added, and the dose 
administered every two or three hours. 

R .— Tinct. aconiti Tfi>. 

Potassi citratis . . . . . . . 3 iv. 

Aquse ammon. acet. ^ij. 

Aqu?e camphorse ad ^viij. — M. 

S. — Take a tablespoonful every hour. 

Generally it will be safe to assist such a diaphoretic by copious 
draughts of warm whey. 



bright's disease, acute. 73 

In severe cases diaphoretic drugs are not to be depended upon. 

Baths are much more certain in their action. The ordinary hot 
bath (104°) may be used, but is objectionable owing to the exposure 
entailed and the difficulties in getting the patient into and out of the 
bath, which, very often, cannot be brought into the sick-room. Leiber- 
meister places the patient in a hot bath at a temperature of 100°, and 
adds hotter water till the temperature reaches 106°, in which he keeps 
the patient from twenty to sixty minutes, after which he is taken out, 
rubbed down, and packed in sheets or blankets for two or three hours 
till a profuse perspiration takes place. 

The writer, always in severe cases where there is any threatening of 
uraemia, has a large vessel brought into the sick-room into which water, 
almost boiling, is poured till it is half filled (into this a few ounces of 
mustard may be stirred) ; a large, thick double blanket is thrown in, 
and in a few minutes wrung out by the attendants, so that the super- 
fluous moisture is got rid of. In this the patient is carefully enveloped 
— all the body being included save the head and face. There is no 
danger of scalding owing to the rapid reduction of heat caused by the 
evaporation from the large surface of the flannel, and indeed there is 
generally some difficulty in having the blanket warm enough. It 
should be as hot as the hands of the attendants can bear when wringing 
it out. 

After envelopment, the patient should be placed upon a mattress or 
palliasse of straw and covered with sheets and blankets for a couple of 
hours till profuse perspiration occur. He is then rubbed dry and 
placed between warm blankets. When in this pack he may drink 
freely of any warm diluent like barley-water or whey. 

The hot-air bath is more convenient though not so certain ; it is gen- 
erally all that is necessary in mild cases. Of it there are two forms — 
one consisting of a large copper spirit-lamp enclosed by gauze, like a 
Davy lamp, and surrounded by a cradle of sticks to keep off the bed- 
clothes. It is lighted and placed between the patient's knees, and the 
bedclothes tucked in lightly all round him, the head and face only 
being left free. Half an hour generally produces a very free perspira- 
tion. The writer has seen one death caused by burns through the 
negligence of a nurse in not watching the patient, but with ordinary 
care an accident is hardly possible with a quiet, conscious patient. A 
second form of bath can be obtained from most surgical instrument 
makers, in which the spirit-lamp is placed on the floor of the room, 
and the heated air caused by the combustion is conveyed- under the 
bedclothes by a wide, tin telescope tube. Perfect safety is thus obtained 
if the nurse does not upset the lamp and spill the ignited spirit over 
carpets and bed-hangings. 

Sir J. Simpson's "poor man's bath" is made by filling a number of 
soda water bottles with very hot water, and drawing over each a 
woolen stocking squeezed out of hot water, and placing them along- 
side the patient under the bedclothes. 

6 



74 bright's disease, acute. 

In ordinary cases the Turkish bath is not available, but it may be 
used in chronic Blight's disease with advantage. 

The hot pack or hot-air bath may be given daily, or even oflener, 
where uraemia is threatening, or where anasarca is very extensive. 
They must, however, be used with some discretion, especially if there 
are marked signs of cardiac failure or great dyspnoea. 

Should all these methods fail in inducing free and abundant perspi- 
ration, the physician has still a most powerful diuretic in pilocarpine, 
and the writer finds that if administered whilst the patient is in the 
pack, it acts more rapidly and safely. From -J- to i of a grain (gener- 
ally i of a grain will be sufficient), when injected subcutaneously, in a 
few minutes produces copious sweating and a very great discharge of 
saliva. It may be given by the mouth just before the patient is placed 
in the pack, and a dose of sal volatile will overcome any depressing 
effect upon the heart. 

Diuretics. — It is advisable to administer mild diuretics, so as to 
wash out the kidney tubes and flush away casts and epithelial debris. 
The best remedy is water in copious draughts, or any diluent drink 
like barley-water or linseed-tea, hot or cold, as the patient wishes. 

Spt. aether, nitrosi and the citrate, or acetate of potash are harmless 
diuretics, whilst squill, broom, gin, juniper, and others possessing a 
stimulating power, are not so safe.' 

Digitalis is the safest and best diuretic, and generally admissible, and 
so is caffeine after the subsidence of the very acute stage. Where the 
tension is high and urinary secretion scanty, the best remedy will 
be found in nitro-glycerin in doses of -J minim of a 1 per cent, solu- 
tion every hour. It often materially increases the secretion of urine 
with promptness. It must be remembered that the action of diuretics 
in Bright's disease is most uncertain end unreliable, and the physician 
must trust to the skin and bowels for the elimination of products whose 
presence in the blood may lead to a fatal issue. 

Purgatives. — Only those are indicated which cause copious watery 
motions. Elaterin and elaterium are generally given in desperate 
cases, and it is in such cases that absorption from the stomach may be 
in such a condition as to render their action void. They are, there- 
fore, not to be relied upon. A dose may have no effect, which in health 
would cause serious purging, and if a second dose be administered, dan- 
gerous prostration might supervene should the absorption of both doses 
take place eventually. 

Pulv. jalapae comp. in drachm doses is the favorite remedy, but the 
best results will be always obtained from sulphate of magnesia. 

R. — Magnes. sulph ^ij. 

Magnes. carb. . . . . . . • Z]- 

Aquae menth. pip B x ij- — M. 

S. — A wineglassful every two or three hours till purging supervene, then 
half a wineglassful every four hours to keep up the discharge of watery motions. 



CHKOXIC. 75 

Another method of giving this drag in cases of great anasarca will 
be presently mentioned. 

Calomel must not be administered, owing to its dangerous depressant 
action in kidney diseases. 

Other symptoms must be met by appropriate treatment. Thus, 
pain in the renal region required the application of hot poultices, and 
if the inflammatory action runs high, local bloodletting by leeches 
or wet cupping over the loins must be resorted to ; and should there 
be fever with a full, bounding pulse, suppression of urine, and signs of 
approaching coma or convulsions, a vein in the arm should be opened 
and ten or more ounces of blood allowed to flow freely from a large 
orifice. Bozzolo after bleeding dilutes the remaining blood by the sub- 
cutaneous injections of sterilized saline solution or serum. 

After the acute symptoms have subsided, counter-irritation over the 
loins may be called for. Mustard answers every purpose, and blisters 
should never be employed. Cupping is unobjectionable. Should 
anasarca remain, the action of digitalis may be kept up,combined with 
the more stimulating diuretics, as broom and juniper. 

The following is a splendid combination at this stage : 

Be. — Tinct. ferri chlor . £vj. 

Liq. ammon. acet. . . . . . . §iij. 

Aquse camphorse ^yj. — M. 

S. — Take a tablespoonful in a wineglassfal of water every four hours. 

The knowledge that potassium salts increase very greatly the danger 
of uraemia should always lead one to use the soda salts in the treatment 
of Bright's disease. In this way, owing to the poverty of milk in potas- 
sium salts, its value in ursemia is supposed to depend. 

Bouchard has insisted upon intestinal disinfectants, as he finds much 
of the toxic substance found in the blood has been reabsorbed from the 
bowel, and he thus gives charcoal, iodoform, and naphthalin. 

Jaccoud, noticing that free work in the open air and a sojourn in 
compressed air both diminish the toxity of the urine by one-half, has 
with success given inhalations of 10 litres of oxygen three times a day; 
and Carter is satisfied that this treatment is as useful in practice as it 
is rational in theory. 

Salicylates and nitro-glycerin may be resorted to in the later stages 
should arterial tension increase, and iodides are useful also. 

The treatment of various complications will be mentioned under 
chronic Bright's disease. 

BRIGHT'S DISEASE, Chronic 

The general treatment of the chronic affection arising out of the 
acute disease, or of the affection which has apparently begun in the 
chronic form, will differ but slightly in degree from the treatment 
mentioned under acute Bright's disease. The diet should be chiefly 



76 bright's disease, chronic. 

milk ; eggs and strong animal foods, or concentrated soups, or stimu- 
lants, must be allowed only in small quantities. Fat and carbohydrates 
are admissible in full quantities. 

The patient's body, when not in bed, must be enveloped entirely in 
flannels, and damp, cold, and rain avoided. A dry, equable warm 
climate, in which an outdoor life may be safely pursued, is a great 
desideratum. 

The artificial koumiss, mentioned upon page 23, is a valuable 
adjunct to the diet in all stages of the disease. 

The same indications are to be met in the chronic form of the dis- 
ease as were discussed under the acute affection. Diaphoretics, diuretics, 
and purgatives are to be judiciously administered. * 

The physician will find at the bedside that he is very often called 
upon to treat subacute or acute attacks occurring upon the top of a 
well-marked chronic affection, and the indications are precisely alike, 
and must be dealt with as promptly as if the attack were one of acute 
Bright's disease happening to a healthy individual. 

If the patient be well enough to go about, the action of diaphoretics 
must, to a great extent, be suspended, and the physician must be con- 
tent to keep the skin in a healthy state of activity by very warm 
clothing, and a hot bath or hot pack at night. Diuretics are of more 
value and more to be relied upon than in the acute form. Digitalis is 
always safe, and may be given in full doses ; the tincture is the best 
preparation when the diuretic action of the drug is required, as it con- 
tains digitalin, digitalein, and digitoxin, by which the maximum effect 
is produced upon the kidney, because all the bloodvessels of the body 
are contracted, whilst those of the kidneys are dilated — a result not to 
so easily obtained when the infusion is administered. 

Notwithstanding the incompatibility between digitalis and iron, the 
combination of their tinctures makes a valuable, though inelegant mix- 
ture, especially indicated in the treatment of this disease. 

Diuretin gives excellent results. 

Caffeine is a good diuretic in these cases, and some authorities believe 
that it diminishes the albumin and increases the elimination of solids. 
The writer, in a series of carefully conducted experiments, failed to find 
that it had any influence in increasing the amount of urea daily 
excreted in chronic Bright's disease. It may be combined with digi- 
talis or spartein. 

Cannabis indica has been found of much service, especially as opium 
is contra indicated. Sometimes it exerts decided diuretic action, and 
leads to rapid improvement where there is much blood in the urine, 
though the rationale of its action is obscure. 

Copaiba, turpentine, and cantharides are powerful diuretics, but 
should be seldom employed, even in the most chronic cases, as irrita- 
tion of a serious nature may follow their administration. It is 
fashionable to order them in infinitesimal doses which can do no 
harm. 



bright's disease, chronic. 77 

Jaborandi and juniper are valuable remedies; the former is indi- 
cated where there is much blood in the urine, and the latter where 
blood is absent and the total amount excreted is small. 

Nitro-glycerin will sometimes start the kidneys to act after all 
other remedies fail. Half a minim of the 1 per cent, solution may 
be given every hour for six or eight doses, then every second or third 
hour. 

Benzoate of soda has been found very serviceable (15 grains four 
times daily) in threatening urremia. The best purgatives are salines, 
and magnes. sulph., as mentioned under the acute affection, is also the 
most reliable cathartic in the chronic disease. Cream of tartar is both 
diuretic and purgative. Purgation can be safely kept up by small 
doses frequently repeated over long periods. Massage is of the greatest 
use in chronic dropsy, as pointed out by Stewart. 

With a view of diminishing the amount of albumin, a host of specifics 
are vaunted ; their action is uncertain, and at the best very slight. 
Lead acetate in small doses, lime-water, belladonna, fuchsin (1 grain 
pills for children), gallic and tannic acids, astringent iron preparations, 
oxygen inhalations, common salt in 20-grain doses, chloral, benzoate of 
soda, ergot, arsenic in 3-minim doses of liquor over long periods, 
hydrastis, and chimaphilia. The above is but a few of the innumer- 
able remedies supposed to diminish the amount of albumen in chronic 
Bright's disease. When such a result follows, as it doubtless often 
does, it is possibly owing to the general tonic action of the drug in 
improving the languid circulation through the renal capillaries. Iron, 
combined with digitalis and nux vomica, upon the whole will give the 
best results. Iodides are also very valuable in all chronic cases. 

Where the anasarca continues to increase, and threaten life, notwith- 
standing the free use of diuretics, hot-air baths, and purgatives, relief 
may be obtained by acupuncture of the most dependent parts. The 
skin should be smeared over with lanolin or boric ointment, and a 
number of smart punctures made with a sharp glover's needle, whose 
point may be freely moved about before withdrawal. Over the mal- 
leoli, dorsum of foot, or calf are the best situations, and the limb should 
be enveloped in warm, moist, flannel cloths, and any tendency to an 
erythematous condition of the skin met by appropriate remedies. Strict 
antiseptic precautions are essential. A Southey's minute canula may 
be left in situ. Should the dropsy continue to increase, the physician 
has still another remedy to try. Hay recommends that 2 ounces of 
magnes. sulph., dissolved in 2 ounces of water, be given when the ali- 
mentary canal is empty, after fasting and total abstinence from fluids 
for twelve or eighteen hours. Sometimes enormous quantities of fluid 
are excreted from the bowels by this method, and the writer has seen a 
water-logged patient rescued upon more than one occasion by this 
means. It, however, unfortunately fails in many cases, owing appar- 
ently to the condition of the alimentary canal. 

Calomel is lately recommended by Mosler for the dropsy and ursemia, 



78 bright's disease, chronic. 



but it is a dangerous remedy, whose action is exceedingly difficult to 
control. Small doses have proved fatal. 

Where ursemic convulsions come on nothwithstanding the above 
treatment, large doses of bromide of sodium and 30 grain doses of 
chloral may be given by the bowel, a hypodermic dose of \ grain of 
pilocarpine whilst in the hot pack, and the inhalation of chloroform or 
ether, afford the best results. Venesection may be tried with advantage. 

These various measures, combined with the prompt emptying of the 
uterus, gave the best hope of life in convulsions coming on at the 
puerperal period, in such cases blood-letting is a valuable remedy. 

The various symptoms and complications occurring during the dis- 
ease will be combated upon general principles. Thus ascites, hydro- 
thorax, and hydropericardium should be treated as part of the general 
dropsy, and if serious embarrassments result from them the fluid must 
be drawn off with the trochar and canula, or by aspiration. 

(Edema of the lungs must be treated by the methods employed for 
the general anasarca, and by sinapisms to the chest, and by the concen- 
trated solution of Epsom salt. On no account should pilocarpine be 
administered in the face of this serious condition, as further oedema 
and death will probably result. 

Vomiting, which is often very troublesome, may be treated by bis- 
muth and iced champagne, but the writer has seen magical results 
from the administration of sour buttermilk in small quantities. He 
was led to use it after observing its value in a case where a patient was 
sinking from intractable vomiting. A constant craving for this acid 
beverage induced a kind-hearted nurse to give it contrary to orders, 
and the vomiting immediately stopped. It appeared to act by neutral- 
izing the free ammonia which seemed to be eliminated by the gastric 
membrane. 

Diarrhoea is best let alone, unless very exhausting. It may be over- 
come by small doses of codeine, and the judicious use of vegetable 
astringents and mineral acids. 

Anaemia, so constantly present, is best met by iron in some form. 

Hemorrhage from the kidneys and other regions will require astrin- 
gents and the hypodermic injection of ergotine. The effects of jabor- 
andi and indian hemp when given by the mouth have been already 
referred to. 

Ursernic dyspnoea is best relieved by drachm doses of sulphuric ether, 
or by nitrite of amy], or nitro-glycerin and brisk purgation. The 
administration of Mexican pulque, the fermented sap of the American 
agave, has been highly spoken of in chronic Bright's disease, and the 
writer is making some observations which he trusts to report at a 
future date upon the effects of this remedy. It appears to act like 
koumiss, and at the same time stimulates the circulation and brain 
slightly. _ 

Sleeplessness is best relieved by sulphonal in 20 to 30 grain doses. 
Opium and morphine sometimes induce serious cerebral disturbance, 



bright's disease, chronic. 79 

and chloral is not to be employed as a routine drug in an affection 
often associated with cardiac disease and degeneration. Paraldehyde 
acta safely and effectually. 

Headache is relieved by caffeine, antipyrine, and antifebrin. 

Hitherto the treatment of the chronic form of Bright's disease, asso- 
ciated with the large white kidney, has been discussed. The variety of 
the affection characterized by the presence of the fatty kidney will be 
treated best upon exactly the same lines, the various symptoms of the 
diseases in which it is met (chiefly phthisis) being dealt with according 
to requirements. 

The treatment of the amyloid or waxy form of the disease will resolve 
itself into the treatment of the cause of the affection, and in the early 
stages of the disease the removal of this may be followed by complete 
restoration. Thus the source of the prolonged suppuration must, if 
possible, be removed, and diseased bone extracted. Chronic abscesses 
may be surgically dealt with, and pulmonary or pleural suppuration, 
when not depending upon tubercle, may be remedied by appropriate 
medicines, incisions, and drainage, with change to a warmer climate. 
Syphilis in its protean tertiary phases may be combated, and the 
patient placed in a fair way toward recovery if the disease has not 
lasted too long. Large doses of iodide of potassium and small doses 
of phosphorus (-o 1 ^ grain) may be followed with benefit, and iron is 
always indicated. 

As the disease is not generally associated with marked diminution in 
the total quantity of urea daily excreted, ursemic symptoms will sel- 
dom be met with, and the treatment by diaphoretics, diuretics, and 
purgatives will seldom be required. Dropsy will seldom require much 
attention, anaemia being the most prominent symptom needing treat- 
ment, and the various complications of the original affection upon 
which the kidney disease depends. 

The cirrhotic form of Bright's disease will be treated upon- much 
the same lines as the other varieties, but as anasarca and loss of albu- 
min play so small a part in the progress of the disease, treatment in 
this direction is seldom required. Ursemic symptoms afford the main 
indication, and in the later stages of the disease the treatment resolves 
itself into that of uraemia, and though the progress of the affection is 
always toward a fatal issue when once thoroughly established, never- 
theless there are few affections in which the physician can so confidently 
feel that he can prolong life by the judicious use of remedies to lower 
arterial tension, and relieve the system from the dangerous accumula- 
tion of effete products by acting upon the skin and bowels. 

Arsenic and iodides, alone or combined, are supposed to exert some 
influence over the primary lesion; their action is, however, very un- 
certain at the best; and if there be any drug whose administration will 
be followed by some constant action upon the pathological process, or 
upon the increased growth of the fibrous stroma, it will be found in 
the chloride of gold, in doses of y 1 - grain three times a day in a pill. 



80 BEOMIDKOSIS. 

Arterial tension may be lowered by small and oft-repeated doses of 
nitro-glycerin, but it is manifest that this treatment cannot be kept up 
for an indefinite time in the course of a disease of many years' dura- 
tion, nor is it advisable to lower it too much. Constant purgation with 
salines every morning, especially with the sulphate of magnesia, Fried- 
richshall or Hunyadi water, may be kept up with much benefit for very 
long periods. In the intervals during which purgatives may be sus- 
pended and the bowels allowed to rest, nitroglycerin and nitrites may 
be given, and hot air-baths or hot packs at night. 

It is needless to say that the causes of the disease should be removed, 
and, at the earliest possible moment, chronic alcoholism, lead poison- 
ing, and gout be actively dealt with. 

Upon the first appearance of dangerous uremic symptoms, the 
physician should purge rapidly, employ the hot wet-pack, and give 
pilocarpine by subcutaneous injection, and try the nitrite of amyl or 
bloodletting. 

BROMIDROSIS. 

The treatment of fetid perspiration, chiefly of the feet or armpits, 
but especially of the former, is a matter of importance, as the victims 
are almost outcasts, owing to the extremely unpleasant odor arising 
from them. The most scrupulous cleanliness must be rigidly enforced 
and the general health carefully attended to. Internal remedies have 
some effect, but though their action is generally unsatisfactory, they 
should have a trial, always, however, combined with local treat- 
ment. 

Belladonna or atropine internally has some influence upon the 
secretion of the sweat, and may be combined with ergot. 

Jjt. — Tinct. belladonnse ^j- 

Ext. ergotse fid ^j. 

Tinct. hyoscyami ^j. — M. 

S. — Take twenty-five drops three times a day in a little water. 

20 grains of boric acid three times a day, along with 20 grains of 
precipitated sulphur, morning and night, may be tried. 

The best local treatment by far is powdered boric acid rubbed into 
the skin and dusted freely between the toes, and generously strewn 
over the inside of the stockings and boots, and repeated twice a day 
or oftener, with change of stockings. Cork inside soles should be 
worn and changed from time to time, or dipped into saturated boric 
acid solution and allowed to dry. Stockings may be treated in the 
same way with advantage. 

This treatment carefully carried out will, in the great majority of 
cases, effect a cure if persisted in. Strong boric ointment may be used 
instead, by those who have long walks to accomplish with very tender 
feet. 



BRONCHIECTASIS. 81 

Bardet uses the following powder, sprinkled inside the stocking 
soles, after washing the feet and rubbing with alcohol : 

H • — Pulv. talcis . £x. 

Bismuthi subnit. ^xj. 

Potassii permang giij. 

Sodii salicyl 3ss. — M. 

Sponging the feet over with the tincture or liniment of belladonna 
is useful; and Hebra used the diachylon ointment spread upon strips 
of linen, and applied morning and night — 8 ounces of the best olive oil, 
boiled with 2 ounces of litharge, and made into an ointment. 

The application of the induced or continuous current is of use ; and 
1 drachm of quinine, dissolved in 10 ounces of alcohol, and sponged 
over the feet, has been followed by removal of the unpleasant symp- 
tom. 

Weak corrosive sublimate solution has been tried, and solution of 
salicylate of soda, oxalic acid, naphthol, and boroglyceride have 
given good results. Unna uses an ointment consisting of equal parts 
of zinc ointment, turpentine, and ichthyol, and dusts in a powder 
during the day composed of 15 grains of powdered mustard and 1 
ounce of talc. 

Where the excessive and unpleasant sweating of the feet is associ- 
ated with the formation of ulcers and abrasions, the dry boric acid 
w T ill often effect a cure, but the use of a 5 to 10 per cent, solution of 
chromic acid as a preventive before ulcers break out, as adopted in 
the German army for tender feet, is of value. The writer has seen 
trouble follow the use of this solution in cases where blisters or ulcers 
had already formed, and several cases of serious poisoning from the 
absorption of the acid are already reported. As the boric acid meets 
all requirements, there is little justification for the use of any remedy 
associated with such risk. If not already given up by the German 
military authorities, it probably soon will. (See also under Per- 
spiration.) 

BRONCHIECTASIS 

will be best treated by attention to the general health and the judi- 
cious use of remedies indicated in wasting diseases, as cod-liver oil, 
malt extract, or hypophosphites. Change of climate, sea voyage, and 
the use of remedies applicable to chronic bronchitis, especially the 
iodide of potassium. 

Creasote holds the first rank as an internal remedy, and is indicated 
in both forms of the disease, whether the enlargement or dilatation of 
the bronchi be general, or only confined to one or more saccular or 
cavernous dilatations. It is in the latter variety that the greatest dif- 
ficulties in treatment present themselves. The pus or muco-purulent 
discharge lying in these cavities becomes very fetid, and can only be 



82 BKONCHITIS, ACUTE. 

reached, in many instances, by remedies eliminated by the bronchial 
mucous membrane. 2 or 3 minims of creasote, three or four times a 
day, in mixture or capsule, sometimes giv.es excellent results, espe- 
cially when the cavity is basilar. Oil of sandal wood, oil of eucalyp- 
tus, carbolic acid and tar, or terebene, or paraldehyde can be given 
upon the same principle. Myrtol, in capsules containing 2 minims, 
four times daily, has given excellent results. 

Inhalations are indicated, and creasote stands first upon the list. 
Chlorine, iodine, menthol, eucalyptus, carbolic acid, terebene, thymol 
or oil of peppermint may be given as an inhalation with hot water, or 
placed in any of the respirators made for the purpose. It is a good 
plan to saturate the air of the patient's room with the vapor of turpen- 
tine, or of the oleum pini pumilio or oleum krummolzol. 

The violent paroxysmal cough, produced by attempts at the clear- 
ing out of the cavity, may be relieved by these inhalations ; if not, 
chloroform or ether may be added, or a whiff of either taken alone. 
Massage may be very useful in assisting the emptying of the cavity. 

Where there is a large cavity, especially if near the middle or base 
of the lung, which cannot be reached by inhalations, and which the 
patient cannot empty by severe coughing, the propriety of making a 
free opening from the outside, and establishing thorough drainage, is 
beyond dispute, especially if the physical signs show that it is near the 
surface of the lung. The writer has found in several cases that the 
patient may be made to empty the cavity by lying in bed, and almost 
inverting his bod}^ by bringing his head near to the floor, supporting the 
weight of his trunk upon his hands, which rest upon the floor. The 
pus sometimes flows out in a stream from the mouth by assuming this 
position. Some patients in stooping to tie their boot-laces, discover 
this plan for themselves. It is a good plan to have a flannel binder, 
moistened with oil of eucalyptus, placed round the chest and abdomen, 
the odor of the oil is given off slowly all day, and is inhaled by the 
patient constantly. 

BRONCHITIS, Acute. 

The mild cases of acute catarrh, involving only the larger divisions 
of the bronchial tree, require little treatment. Where the patient per- 
sist in going about and attending to his ordinary duties, the physician 
should be careful not to prescribe the remedies indicated where the 
affection is more severe, and where the patient is confined to his room. 
Thus diaphoretic remedies, sprays, and inhalations render the patient 
more susceptible for the time, and should he expose himself immedi- 
ately afterward, a mild attack of bronchial catarrh may be converted 
into one of capillary bronchitis. A hot bath at bedtime, followed by 
a large mustard poultice and one dose of morphine, t grain, upon lying 
down will give relief during the night, and sometimes will cut short the 
attack. For administration during the day, 5 minims of liquor mor- 



BRONCHITIS, ACUTE. 83 

phire (grains iv to 13J) and 10 minims of vin. ipecac, may be given 
every few hours. Where the attack, though limited to the larger 
bronchi, is much more severe, and is ushered in by some feverishness 
and dry harassing cough, with sense of constriction and rawness in 
the chest, the patient must be confined to his bed or his room, which 
should be kept at an even temperature a little over 60° F. 

The air should be rendered moist by the vapor of hot water. For 
this purpose the ordinary bronchitis kettle placed upon the fire is best, 
or a few feet of tin tubing attached to the spout of the kettle will do. 
The numerous spirit-lamp contrivances so much used should be strongly 
condemned. The unwholesome products of combustion escaping into 
the confined air of the room aggravate the cough, and add to the bron- 
chial irritation. It is not an unusual event to find the cough cease 
when they are discontinued. Plenty of warm drinks should be ad- 
ministered, and there is nothing more grateful than home-made lemon- 
ade mixed (just before being swallowed) with kali water, the resulting 
citrate of potash formed by the combination being one of the most 
valuable of diaphoretics and expectorants, or the following mixture 
may be prescribed : 

R. — Potas. bicarb. ^j. 

Tinct. aconit. . TTlviij. 

Aquse . ^xij. — M. 

S. — Take two tablespoonfuls, with a tablespoonful of fresh lemon juice, every 
four hours. 

At this stage the chief indication is to combat the dry, swollen, and 
congested condition of the bronchial tubes, or, as Sir Andrew Clarke 
puts it, " to. cause the tubes to sweat," and there is no remedy equal to 
small and repeated doses of tartar emetic. These may be administered 
after the first twenty-four hours, and are combined with morphine to 
.great advantage thus: 

K . — Antim. et potass, tart gr. j. 

Morph. acet gr. jss. 

Yini ipecac. . . . . . . . 3 ij . 

Aquse camph ad ^jvj. — M. 

S. — A tablespoonfnl to be taken every three hours. 

A large poultice of linseed and mustard should be applied to the 
front of the chest to cause thorough redness of the skin, and when it 
becomes so irritating that it can no longer be borne with comfort, it 
should be replaced by a layer of warm cotton wool, and another poul- 
tice of the same kind applied to the back of the chest. Where there 
is much dyspnoea, the poulticing may be continued throughout by 
applying plain linseed poultices every two or three hours after the 
linseed and mustard have caused redness. 



84 BRONCHITIS, ACUTE. 

In the case of children the same treatment may be carried out, only 
morphine or opiates should not be given. The little patient will, how- 
ever, bear almost as large a dose of antimony and ipecac as an adult. 
For a child two years old the following may be given in teaspoonful 
doses every two hours : 



Vini antim. 


3J 


Vini ipecac. 


3ij. 


Liq. ammon. acet. 


3iv. 


Syr. tolu. . 


3 iv 


Aquse 


• ad - ifij- 



-M. 

The action of the expectorant is assisted by a hot bath beforehand. 
A smart purge is of use, and in gouty subjects affords marked relief. 
A teaspoonful of Kochelle salt for children, preceded by 1 or 2 grains 
of gray powder; and in adults a 5 grain blue pill, followed by a couple 
of wineglassfuls of Friedrichshall water, may be given. 

Under this treatment the harassing dry cough gives place to a moist, 
easy, and loose expectoration, after which the antimony may be dis- 
continued, and the following administered in teaspoonful doses after 
meals : 

K. — Potas. iodidi. 3j. 

Vini ipecac ^iij. 

Spt. chlorof. gij. 

Inf. senegse ad ^iv. — M. 

S. — To be used as directed. 

Or, 

R. — Amnion, carb 3J. 

Spt. ammon. arom giv. 

Aquse cinnamom. ...... ad ^vj. — M. 

This may be given in doses of a tablespoonful, with water, every 
four hours. 

Ammonia may also be given in the first stage of the affection with 
advantage, if there be any indication for a stimulant. Should the 
cough appear to be out of proportion to the amount of expectoration 
present, it can be allayed with anodynes, but no greater mistake can 
be made by the physician than simply to order morphine or chloral 
to quiet cough when the tubes are filled wilh secretion. In young and 
also in aged patients this practice will be followed by fatal results. It 
checks the expectoration, and renders it more tenacious; at the same 
time sensibility being diminished, the cough does not occur, and the 
secretion gathers in the tubes. 

Where the inflammation of the bronchial tubes has extended as far 
as their finest divisions, the physician will find himself face to face 
with a very grave malady. Here, in addition to warmth in bed and 



85 

steam inhalations and poultices, morphine must be most cautiously 
exhibited, if given at all, and in the old or very young it must be 
withheld altogether. 

As in the milder form, antimony should be given at once and in 
larger doses, and it should be combined from the beginning with am- 
monia, and given every two houjs till the dry and swollen condition 
of the tubes is remedied. 



. — Vin. antim. .... 


. 


3iv. 


Spt. ammon. aromat. 




3j. 


Spt. chlorof. .... 




3ij- 


Aquse ammon. acet. 




gij- 


Aquae . . . . 


ad 


3viij.— M 



S. — Take a tablespoonful every two hours. 

Tinctures of belladonna and benzoin comp. in equal quantities (5J to 
gij) may be inhaled every few hours with the vapor of boiling water. 
Succus conii may be similary employed. The B. P. extract is useless. 
Should there be much pulmonary engorgement, bloodletting may be 
called for, though this will be seldom. Leeching is useless ; but relief 
will be obtained by dry cupping over the front and back of the chest, 
and sometimes a cantharides blister will be called for. 

Apomorphine is a drug of great power, and, pushed to the verge of 
vomiting, it speedily causes abundant secretion of thin expectoration. 
By the mouth it can often be taken in doses up to \ or 1 grain without 
causing vomiting, as pointed out by Murrell. Should relief to the 
breathing and cough not be obtained by these measures, vomiting 
should be established by the use of a nauseating expectorant. Two 
drachm doses of vin. ipecac, \ grain of apomorphine, or 1 grain of 
tartarized antimony should be given, followed by copious warm drinks 
till vomiting supervene : -^ grain of apomorphine will be certain to 
cause profuse vomiting in strong adults, if given hypodermically, in 
five to ten minutes or less. Half this dose is sometimes sufficient. 

The treatment by emetics, seldom required in adults, must be a part 
of the management in every case of severe capillary bronchitis in 
children, and the physician should see that vomiting occurs twice a 
day or oftener, vin. ipecac, being the best remedy. The act of vomit- 
ing in young children is not followed by the depression observed in 
adults, but it should never be allowed to cause serious prostration. 
Young children should be wakened up occasionally, and caused to 
cough or vomit to prevent accumulation of mucus in the tubes. 

Alcohol or wine whey should be administered in proportion to the 
debility present, and alcohol given in warm drinks is a valuable ex- 
pectorant at this stage, and is absolutely necessary in acute bronchitis 
in the aged and in very young and delicate children. 

Inhalations of compressed air and oxygen, saturated with warm 
moisture, have been successfully employed ; and the writer, in 1874 



00 BRONCHITIS, ACUTE. 

treated a patient by inhalations of ozone. Oertel recommends the in- 
halation of cold air. 

In acute bronchitis in patients suffering from valvular lesions, digi- 
talis in full doses, combined with ammonia or ether, is indicated. 

R. — Tinct. digitalis gij. 

Spt. ammon. aromat ^j. 

Spt. setheris . . . . . . . . giv. 

Spt. chlorof. SJij. — M. 

S. — A teaspoonful in a small wineglassful of water every three hours. 

Tincture of lobelia — a dangerous remedy in the weak, or in those 
suffering from heart troubles — may be given in 30 minim doses if there 
is much bronchial spasm. 

Turpentine, in 30 minim doses, is a powerful expectorant and stimu- 
lant in cases where the depression, caused by antimony and ipecac, is 
an element of danger. 

Pilocarpine often increases the expectoration rapidly, but it must be 
given with caution. 

Bryonia, aetata racemosa, sanguinaria, muscarine, and many other 
drugs are recommended as expectorants in the early stages of acute 
bronchitis. It is wiser for the young physician to select the older 
remedies : Tartar emetic, ammonia, ipecac, etc., whose values are 
established by long experience. By closely watching the effects of 
these agents, he will soon find that by varying the dosage and intervals 
between the doses, that he can accomplish almost anything with any 
one of them. 

After a few days the expectoration will become "loose" and more 
abundant. It will now be wise to stop the tartar emetic, and give a 
little ipecac and squill with ammonia. 

R. — Vin. ipecac ^iv. 

Tinct. scillse giv. 

Spt. ammon. aromat. . . . . . g vj. 

Syr. tolu ad giij— M. 

S. — Take a teaspoonful four times a day in water. 

Apomorphine in small doses, ^ grain, maybe continued all through 
the attack with advantage. 

Iodide of potassium, at a later stage, is the best drug we possess, and 
chloride of ammonia may be combined with it in senega infusion. 

The diet should be of the most sustaining kind. Milk and whiskey, 
with strong soups, beef-tea, Valentine's beef-juice, and Brand's essence, 
given in small doses at very short intervals, oysters, fish, and farina- 
ceous foods. Everything that interferes with the free play of the 
diaphragm must be watched, and flatulence and constipation corrected. 
Sleep may be urgently needed, but opium and morphine should not 



87 

be given. Chloral, in small doses, often soothes cough and promotes 
sleep, but its effects upon the heart must be watched. Paraldehyde 
(1 drachm) or sulphonal (30 grains) will be valuable, but the patient 
should not be allowed to sleep long at once. 

In children collapse of the lung, as evidenced by signs rnd symp- 
toms, must be met by vigorous treatment till the shallow breathing, 
lividity, and drowsiness pass off. The patient should be plunged into 
a bath of hot water, to which mustard has been added, and afterward 
treated by a dash of cold water till free and deep respiratory move- 
ments take place. 

Artificial respiration may be kept up, and a weak, interrupted 
current, if at hand, will do good. Afterward free stimulation with 
ammonia, and small doses of brandy, with smart sinapisms to the chest- 
wall, and a limited allowance of sleep at one time, will be the best 
means to meet the collapse. 

Quinine, so much recommended in acute bronchitis, and even in the 
serious complication just mentioned, is, according to the experience of 
the writer, a mistake. He has frequently seen marked embarrassment 
caused by the action of one large dose in drying up the expectoration 
and rendering it adhesive and difficult to be expelled. Musk may be 
given with advantage in such cases. 

Professor Gairdner has philosophically worked out the complex 
problem of the action of expectorant remedies, and has arrived at the 
conclusion that expectoration is far more dependent upon the expulsive 
mechanism of the muscular fibres than upon alterations in the amount 
of consistency of the secretion. To these muscles he gives the name of 
"scavenger muscles" of the respiratory tract, as they perform for the 
luugs and bronchi the same service as the intestinal peristalsis in the 
case of the digestive tract. He therefore urges that in the treatment 
of bronchitis, the so-called expectorants should be prescribed as excitors 
of the bronchial peristalsis, in the same sense as cathartics are excitors 
of the intestinal peristalsis, or as ergot is an excitor of the uterine action. 
This action is, in his opinion, to a great extent independent of vomit- 
ing, and also even independent of change in the density and adhesive- 
ness of the expectoration, and that all the necessary effects of carefully 
regulated doses of squill, ipecacuanha, or tartar emetic may be obtained 
without observing any appreciable general increase of the excretion, 
such as is presumed to take place by those who hold that increase in 
quantity of the bronchial secretion is the primary cause of the thera- 
peutic action of expectorants. For the views of the writer and the 
important experiments of Rossbach, the reader is referred to the fifth 
edition of Pharmacy, Materia Medica, and Therapeutics, page 363. 

BRONCHITIS, Chronic. 

Treat the cause, if possible. Thus, if dependent upon the inhalation 
of foreign particles, the patient must change his environment, and any 
occupations necessitating the breathing of a dusty atmosphere. If the 



88 BRONCHITIS, CHRONIC. 

patient's means permit, removal to a warmer and drier climate is neces- 
sary. If gout be the cause (this is frequently so in dry catarrhs), this 
malady will require careful attention. Should the chronic catarrh be 
caused by long standing congestion of the bronchial mucous membrane, 
the result of valvular lesion or cardiac failure, much can be done by 
strengthening the heart and improving the circulation. In those cases 
where faulty elimination of effete matters by the kidney appear to 
aggravate bronchial trouble, the treatment for chronic uraemia will 
give relief. The presence of emphysema will be an indication for 
tonics and measures directed to the maintenance of the general health. 
The physician endeavors, when the case is not of very long standing, 
to act upon the bronchial mucous membrane, so as to modify or alter 
the diseased action. 

Iodide of potassium, arsenic, and iron, alone or combined, are very 
useful for this purpose, and there is the further advantage in employ- 
ing iodide of potassium that it is one of the best expectorants, rendering 
the sputum more liquid and remedying its tenacious or adhesive quality, 
and it is the best drug for bronchitis associated with difficulty of 
breathing or asthma. Various methods of employing inhalations of 
compressed air have been employed, and Waldenburg has obtained 
excellent results by means of a gasometer, with a tube containing a 
valve and ending in a mask for the mouth and nose. The patient is 
recommended to inspire for ten to fifteen minutes, three times a day, 
air under a slight pressure. The valve or stopcock is then reversed, 
and, by the adjustment of weights, the air is rarified and the patient 
by expiring into this rarified air for a few minutes, counteracts any dis- 
tention of the air-cells or alveoli, and materially benefits any pulmo- 
nary emphysema present. 

Various forms of pneumonic chambers are in use on the Continent, 
and the patient on entering can either inspire compressed air or expire 
compressed air into rarified air. 

Should the cough be dry and the efforts at expectoration difficult, 
the physician will have to satisfy himself, by close examination of the 
symptoms, whether the patient is not coughing much more than is 
really necessary to get up the expectoration. This is a point of vital 
importance in the treatment of chronic bronchitis. Upon the decision 
arrived at will depend the administration or prohibition of sedative 
remedies. By checking cough, much good will be done if this cough 
can be seen to be useless, but if by checking cough, expectoration accu- 
mulates in the tubes, much harm may result. Morphine or opiates 
should, therefore, in the chronic as in'the acute disease, be administered 
with great caution, and if the physician is in doubt he should order 
only small doses to be suspended if lividity or drowsiness appear, and 
by prescribing a stimulating expectorant along with the sedative, the 
minimum of risk is encountered. 

Given, then, a case of dry catarrh, with much difficult cough and 



BRONCHITIS, CHRONIC. 89 

little expectoration of a thick adhesive kind, the best treatment will be 
a mixture like the following:: 



R . — Potas. iod. . 
Potas. bicarb. 
Amnion, chlor. 
Morph. hydrochlor. 
Aq. cinnamom. 



gr. xxxv. 
. giv. 

• 3ij- 

• gr- jss. 

ad ^viij.— M. 



S. — A tablespoonful every four or six hours, or a teaspoonful every two 
hours. 

Or, 

R. — Apomorph. hydrochlor. ... . . . gr. ij. 

Codeina? gr. iij. 

Yini ipecac 3yj. 

Glycerini et aquse . . . . . .ad ^ iij - — M. 

S. — Take a teaspoonful every three hours. 

Alkaline salts have the power of diminishing the viscidity of the 
expectoration, and hence the value of various mineral waters. Where 
from any cause there is fever present, as in bronchial attacks in phthisical 
patients, there is no combination gives such relief as a solution of 
bicarbonate of potash in effervescence with lemon juice, the citrate of 
potash being a valuable expectorant. -^ grain of morphine may be 
added to each dose. (See formula upon page 83.) 

In cases of chronic bronchitis associated with profuse purulent or 
muco-purulent expectoration, morphine or other sedatives are not to be 
administered, for, as pointed out by Burney Yeo, remedies are indi- 
cated which have -a specific action upon the inflamed membrane, and 
to this important class belong all the volatile expectorants and those 
containing some active ingredient excreted by the bronchial surface : 
ammonia, ammoniacum, asafcetida, balsams of Peru and tolu, copaiba, 
creasote, guaiacol, getroleum, cubebs, eucalyptus, sulphur, garlic, tar, 
terebene, turpentine, myrtol, camphor, terpin hydrate, terpinol, oil of 
sandal wood, and many others. 

It is impossible to enumerate the special indications for each par- 
ticular expectorant ; unfortunately, we do not know the class of case 
in which some will fail and others will succeed until we try, and occa- 
sionally the physician will find himself combining several in one pre- 
scription — mitrailleuse-like. 

Tar is about the best member of the group. It may be given in 
capsules, pills, or mixture, emulsified with suitable excipient, but tar- 
water (1 : 10) taken in wineglassful to half-pint doses, is the least 
elegant, but most efficatious, preparation. Ringer and Murrell found 
2 grain pills every three or four hours most efficacious in winter cough 
and bronchitis with profuse expectoration. Yeo advises inhalations of 
tar by forming a spray of the water by means of a Seigle's spray pro- 

7 



90 

ducer, and he adds 10 per cent, of carbonate of soda to good ship's tar, 
to neutralize the irritating pyroligneous acid, and boils the mixture on 
a plate over a spirit lamp in the patient's room for fifteen minutes once 
or twice a day. 

Creasote may be given in capsules, and the internal administration 
supplemented by inhalations, fumigations, or sprays. It is the best 
remedy where there is any trace of fetor in the expectoration. Lantier 
gives small capsules containing the essence of pinus pumilio. 

For the chronic bronchitis of the aged, ammoniacum is a most valu- 
able expectorant. It relieves wheezing and promotes expectoration, 
and the writer obtained splendid results in a large infirmary of aged 
invalids with the following inelegant stock mixture : 

K- — Ammon. chlor. ....... ^j. 

Aquse ammonise . . . . . . . . ^j. 

Spt. camphorae . . . . . . . ^iij. 

Mist, ammoniaci ad ^xx. — -M. 

S. — Take a tablespoonful four times a day in water, the bottle being well 
shaken. 

Terebene, in doses of 10 to 15 minims in capsule or upon sugar, is a 
good remedy in winter cough and in brochitis with emphysema. It 
may be used as an inhalation. 

Squill, senega, ipecacuanha, actsea, lobelia, serpentaria, checken, 
grindelia, hydrastis, physostigma, sanguinaria, stramonium, hyoscya- 
mus, and belladonna have been all tried with success from time to time 
in the treatment of chronic bronchitis. Most of them have already 
been referred to under acute bronchitis. The favorite remedy in the 
chronic and subacute attacks of bronchitis in childhood, and the most 
convenient and safest, is a mixture of equal parts *of wine of ipecac 
and syrup of squill. For a child one to two years old, 10 to 15 drops 
every three hours, and as an emetic, 1 teaspoonful. There is perhaps 
no combination or mixture so universally used as the following in 
chronic bronchitis with emphysema. Patients stick to it for years after 
discarding all others. Perhaps it owes its virtue chiefly to the ammonia 
contained in it. Harris states that of all the drugs which he has em- 
ployed, he gives the preference to the carbonate of ammonia in chronic 
bronchitis. 

R. — Ammon. carb. . . . . . . ^iv. 

Tinct. opii camph. gvj. 

Syr. senegse . . . . . . . giv. 

Infus. senegae ad IJviij. — M. 

S. — Take a tablespoonful four times a day in a little water. 

Strychnine, by stimulating the respiratory centre, becomes a valu- 
able expectorant. It may act also according to Gairdner's theory, by 
stimulating the "scavenger" muscles and increasing the activity of 



BKONCHITIS, CHKONIC. 91 

the expulsive mechanism in the bronchi. It may be combined with 
belladonna with great advantage where there is much secretion and 
weakened expulsive powers. 

Though the list of expectorants contains more than one hundred 
remedies of undoubted value, the physician will find that most of the 
cases of chronic bronchial trouble can be well combated by one or 
more of the following list, beyond which the writer seldom finds it 
necessary to travel : Apomorphine, alkalies, ammonia, tar, ipecac, crea- 
sote, potas. iod., and senega, and perhaps the greatest of all these is 
apomorphine. 

Cocillana has recently been used as a substitute for ipecacuanha, in 
doses of 5 to 8 minims of the fluid extract. 

For chronic bronchitis with exceedingly profuse discharge, i. e., cases 
of bronchorrhoea, an occasional emetic and full doses of a mixture of 
ammoniacum, ammonia, and senega afford the best treatment. Opium 
or sedatives are fatal if given in even fair doses. 

Reference has already been made to the use of sprays and inhala- 
tions in chronic bronchitis. As a rule, it may be said that too much 
reliance should not be placed upon their use, and many maintain that 
they are useless. Ringer and Murrell have obtained excellent results 
from a spray of vin. ipecac, in winter cough. This spray is used by 
atomizing the ordinary vin. ipecac, with a Richardson's apparatus 
or with a steam atomizer; generally the wine does best diluted with 
an equal bulk or more of water. About two drachms of the wine are 
sufficient for each sitting, and after a few trials the patient succeeds in 
taking it in deeply. 

Lobelia, antimonial wine, and iodide of potassium, 2 per cent, solu- 
tion, have all given excellent results in chronic winter cough in the 
hands of Murrell. - 

" Spirone " is stated to be a solution of iodide of potassium in gly- 
cerin and acetone. Harris, in a very able paper recently, mentions 
this latter fact, and states that terebene, pinol, and chloride of ammo- 
nium have been used as sprays with success. 

Chloride of ammonium, inhaled from a " chloride of ammonium 
inhaler," is of undoubted value, especially in cases of chronic catarrh 
of the trachea, larynx, and larger bronchi. 

Eucalyptus, carbolic acid, creasote, and most of the volatile expec- 
torants and antiseptics, are of value when administered as inhalations, 
especially where there is marked fetor or decomposition of the bron- 
chial secretion. 

Any of the volatile drugs can be used as an inhalation, by simply 
adding them to boiling water and then inhaling their vapor in combi- 
nation with the steam given off by the water. Friar's balsam or the 
compound tincture of benzoin, is the most frequently employed. 

The writer has had great satisfaction with turpentine. By saturat- 
ing the air of the room with it, much good can be done in chronic bron- 
chitis, and if hemorrhage be present there is no remedy equal to it. 



92 BRONCHITIS, CHRONIC. 

It can be poured upon the surface of boiling water in large open ves- 
sels, placed about the patient's bed. 

The antiseptic volatile expectorants may be placed in a respirator 
and worn for hours during the day. The following is a good formula : 
Thymol, half a part ; carbolic acid and creasote, of each one part ; 
spirit of chloroform, four parts. Dr. Baner has recently reported 
good results from using a spray of liquefied vaseline in both acute and 
chronic bronchitis. 

The oleum pini pumilio is an agreeable and efficient alterative and 
expectorant when inhaled. 

Counter irritation is of value in chronic bronchitis, and it may be 
accomplished by iodine, acetic acid, croton oil, capsicum, mustard, 
tartar emetic ointment, or any other irritant, but, as a rule, the vola- 
tile expectorants, which are also revulsives, are much superior. Thus 
the lin. tereb., or lin. tereb. acet., or Stokes's favorite application, of 
which the following is a modified formula, may be employed : 

R.- 



Olei tereb 


• • • • liij- 


Acid acetici .... 


• 3 xi J- 


Ovi vitellum 


• j- 


Olei limonis . . . 


• 33- 


Aquse rosse .... 


. . . ad gvj.— M 



Or, the oil of eucalyptus with camphor may be tried. 

The value of these applications lies (1) in their revulsive action ; 
(2) the friction assists the expulsive efforts, and dislodges collections of 
mucus ; (3) the vapor clings to the skin and clothes of the patient, 
and is gradually inhaled ; and (4) a minute trace also is absorbed 
through the unbroken skin, and reaches the pulmonary tract through 
the blood. 

Massage, or manual compression of the chest and abdomen in expi- 
ration, recommended by Gerhardt, is useful where, owing to bronchial 
dilatations, or cavities, or weakness in the expiratory apparatus or 
mechanism, accumulations of secretion are liable to occur. 

Where the patient's means afford it, there will crop up the question 
of a suitable winter residence, and a sojourn at any of the Continental 
Spas, where the free use of alkaline waters may be tried, as at Braum, 
Soden, Ems, Mount Dore, etc., or any place at home where natural 
sulphur water may be had. If the patient finds that a warm, dry air 
suits his breathing, he may go to Mentone or San Remo, or if a still 
drier atmosphere is desired, Egypt or the Nile, Algiers or Tangiers 
will be best. Should, however, a soft or sedative air be desired, 
Madeira, Pau or Torquay, Penzance, Bournemouth, or Isle of Wight 
may be recommended. 

Bronchial irritation in young subjects where the supervention of 
tubercular phthisis is feared, will be well treated by a prolonged resi- 



BRUISES — BUBO. 93 

dence at the pine forests of Arcachon, or at Bournemouth, nearer 
home. 

BRUISES. 

If seen early before discoloration has already occurred, may be best 
treated by the application of cold. Ice or evaporating spirit lotion is 
the most effectual. A cold saturated, recently prepared solution of 
chloride of ammonium is a good application to orbital contusions 
where a "black eye 1 ' is dreaded. The juice of the fresh root of con- 
vallaria (Solomon's seal) is reputed to be of great value for the same 
purpose. Arnica, so much recommended for this .purpose, should be 
used with extreme caution. It is of little or no value, and often pro- 
duces dangerous erythematous rashes, which may spread from the site 
of application over the entire body. 

Should extravasation of blood or ecchymosis already have taken 
place, warm spirit lotion, covered with oiled silk, and padded over 
with thick layers of cotton wool, and bandaged moderately tightly, 
will do more than anything else to cause absorption of blood. Capsi- 
cum, camphor, and mild counter-irritants may be afterward used to 
hasten the process. Pain is best relieved by opium, aconite, bella- 
donna, or acetate of lead. 

The application of leeches occasionally prevents discoloration, if 
used very early. 

BUBO. 

Confining the term to an indurated and often suppurative condition 
of the glands in the groin, secondary to a venereal sore on the penis, 
the first treatment should be directed to the sore itself, and all irrita- 
tion or inflammation in it should be at once attended to. If the bubo 
is only in the early stage, it may be prevented from suppurating by 
freely painting the skin over it with very strong solution of nitrate of 
silver, or by moistening the skin and rubbing with the solid nitrate. 

Saturated solution of iodine, in spirit, may be used. The writer has 
obtained excellent results by painting the skin over the enlarged gland 
with iodized phenol (iodine, 1 ounce; carbolic acid, 4 ounces). 

Ice or evaporating lotions may be applied and rest enforced. The 
heroic method of injecting carbolic acid or of applying blisters, fol- 
lowed by iodine, is not to be advocated. The state of the patient's 
general health should be narrowly examined, and tonics, aperients, 
and liberal diet, with a change to the sea air, if possible, in bad cases, 
may be necessary. Should the swelling have lasted too long and there 
be pain and redness, a good linseed poultice should be applied. But 
if the hope of preventing suppuration is not altogether out of ques- 
tion, the physician should not hesitate to apply a poultice ; sometimes 
by relieving tension it saves the part from suppuration. If matter has 
already formed in the gland, it will be obvious that a few poultices, 



94 BUNION. 

followed by a free incision, is the best treatment, and if there has 
been much sloughing of the surrounding tissues, and a great enlarge- 
ment of the glands, they ought to be excised. 

The sore resulting from ulceration or incision may be swabbed out 
with corrosive sublimate solution (1 : 500) or iodized phenol, and 
dressed with spirit, lead, carbolic or chlorate lotion, or dusted over 
with iodoform. 

Should healing be very slow or indolent, a light brush over with 
nitric acid or acid nitrate of mercury, and after -dressings of solution 
of chloral (1:30) or peroxide of hydrogen will hasten recovery. In 
very chronic cases the agents detailed under Ulcer may be used 
after failure of the above, but in most chronic cases there is no drug 
so uniformly successful as iodoform. It may be dusted over the sore 
or used as an ointment (1 drachm to 1 ounce). 

BUNION. 

The only treatment followed by lasting benefit is to remove the 
cause, by insisting upon a wide- soled boot, with square, roomy toes and 
low, broad heels. The deformed large toe is to be drawn inward into 
line with the inner border of the foot, maintained in this position with 
strapping, or with Say re's buckskin glove, into which the toes fit, and 
which is kept in position by a piece of India-rubber webbing fastened 
to the heel with plaster. 

Instrument makers supply a bunion spring, but it is not comfortable. 
The writer has had good results with a simple piece of leather moulded 
when wet to the great toe, as it is held in position in line with the 
inner border of the foot. This is fastened on in the evening and worn 
until the next morning. 

Liniment of iodine applied daily reduces induration and relieves 
pain. Should inflammation have supervened, rest must be enforced 
and the swollen joint treated with evaporating lotion (lead and opium 
or spirit), and if suppuration occurs, a free incision. Relief in slight 
cases may be obtained by wearing a neatly fitting felt plaster with a 
hole cut in its centre. 

Another method of treating bunions is given in Sajous's Annual. 
The foot is well washed and dried, after which the healthy skin sur- 
rounding the bunion is then coated over with a layer of flexile collo- 
dion for protection. Carbolic acid in the crystalline form is then 
thickly laid on over the bunion, and the superfluous acid removed by 
blotting paper. The applications are made every three or four days. 
This can only be of use in very mild cases. 

Where ordinary measures fail, and the deformity canses both pain 
and inconvenience, various surgical procedures may be tried. These 
have been recently reviewed by Fowler, who condemns the plan of 
cutting the tendon of the extensor proprius pollicis, with or without 
section of the external lateral ligament of the joint. Unless where 
suppuration and caries have supervened, subperiosteal resection of the 



BURNS AND SCALDS. 95 

head of the metatarsal bone is not a justifiable procedure, as it short- 
ens the inner margin of the foot unnecessarily. 

Cuneiform osteotomy does not give satisfactory results, and partial 
resections or removals of the outgrowths have generally failed, owing 
to the nature of the tissues forming the margins of the skin wound 
which is made upon the inner aspect of the joint, and owing also to 
the exposed situation of the cicatrix. Hunter, by utilizing Petersen's 
incision for tubercular disease, has overcome all these difficulties. He 
attacks the diseased spot by an incision along the outer side of the 
metatarsal bone, dividing all the structures between the dorsum and 
sole of the foot, between the first and second metatarsal bones, and 
then opens the joint, after strongly adducting the great toe. The head 
of the bone can then be easily removed, when it is the site of the 
usual exostosis. The after-treatment is conducted upon general sur- 
gical principles, care being taken to provide efficient drainage, and, 
after the healing process is completed, a partitioned shoe and glove- 
stocking afford great comfort. 

BURNS AND SCALDS. 

When the skin has been for a short time submitted to even an in- 
tense heat, if a saturated solution of bicarbonate of soda be instantly 
applied, no vesication or destruction of cuticle occurs, and pain is al- 
most instantly relieved. In this simple way, what would otherwise 
have been a troublesome and painful burn, will be effectually pre- 
vented. But the application must be made without delay, and before 
the cuticle is raised, and the quickest way is to apply the dry salt 
made into a paste with a little water, and gently rubbed over the 
smarting spot for a few minutes, adding a few drops of water from 
time to time. The first treatment required in the case of severe and 
extensive burns is to relieve the shock and collapse by enveloping the 
patient in flaunel or wadding, and administering liberal doses of hot 
stimulants — whiskey punch or wine whey — relieving pain by full doses 
of laudanum, and whilst this is being done, only very limited atten- 
tion can be bestowed upon the burn itself. The clothing should be 
carefully cut off, piecemeal, and only a limited portion of the surface 
of the body should be exposed at one time. 

Corrosive liquids, if they have been the cause of the burn or scald, 
should be washed off with an appropriate solvent. Thus, scalds by 
boiling acids should be lightly washed with warm w r ater or weak 
alkaline solutions, and boiling tar scalds can be gently cleaned with 
any warm bland oil or lard. 

Immersion of the body in cold water after extensive burns is a very 
questionable proceeding, and many deaths have been caused in this 
way ; but a burn in the first degree, affecting a limited area of the 
body — say one limb — may be well treated by immediately enveloping 
the limb in cold water dressings. Where a very large surface of the 



9b BURNS AND SCALDS. 

body is burned, and the patient is suffering great pain, relief may be 
obtained by immersing the patient in a bath at about 98° F. 

In dealing with a burn of the first or second degree, whether large 
or small, the first indication is to exclude the air as soon as possible ; 
if blebs have formed, they should be punctured at their most depend- 
ent parts through a small aperture — thus saving as much as possible 
of the cuticle as a covering to the injured skin. One method is to 
dust over the entire part with a thick coating of wheaten flour, upon 
the top of which is placed a soft uniform layer of cotton wool, covered 
by bandages. 

Should this plan be adopted, the writer would suggest that the flour 
be mixed with some finely powdered boric acid, say 1 to 4. The prac- 
tice of Ostermayer is an improvement. He uses a powder of potassium 
sozoiodol mixed with starch or talc-powder in 10 per cent, strength. 
It has the advantages over most other applications in being without 
odor and non-poisonous, and it prevents suppuratien. 

Powdered iodoform is used in the same way, but it lacks these prop- 
erties ; it is, however, a local sedative. 

Salol, thiol, bismuth, and other powders have been used alone, or 
with talc or oxide of zinc. 

Whatever will enable the first dressing to remain on for the longest 
possible period with safety is an advantage, and these bland antiseptics 
will delay putrefaction. 

The list of dressings and applications for burns is practically end- 
less. Nearly every surgeon has his own favorite; by far the most 
frequently used is the old-fashioned carron oil, or some modification 
of it. It is, after all, the best routine treatment for burns and scalds. 
When house-surgeon to a large hospital for two years, the writer 
treated all burns admitted by covering them up as soon as possible 
with broad bands of lint soaked in the following : Lime-water and 
olive oil, of each one gallon; pure carbolic acid, 6 ounces; and he 
has never seen a better application. The carbolic acid delays the date 
of the change in the first and subsequent dressings. 

Illingworth recommends a dressing which probably will prove supe- 
rior to this old-fashioned and tried agent. It is a modification of it, 
and consists of equal parts of saturated solution of borax and linseed 
oil. The writer has not yet had an opportunity of using it. 

Upon each change of dressing, if suppuration has occurred, the 
surface should be syringed with a weak antiseptic (boroglyceride, 2 
ounces ; water, 20 ounces). 

Burns of the third degree may be treated in the same way. Hebra's 
method was to keep the patient in a warm bath for weeks. 

The pain is somewhat relieved by the carbolic acid, iodoform, or 
salol mentioned in the above dressings, but when it is intense there is 
no remedy equal to cocaine, and it may be applied in solution from 2 
per cent, where a very large surface of the body is involved, to 5 per 



BURNS AND SCALDS. 97 

cent, or more in less extensive burns. It is of little use unless when 
the cuticle has been removed. 

The free use of strong antiseptic applications may retard the separa- 
tion of the sloughs, and it is especially desirable that this should not 
be, hence hot applications are indicated. These may be applied whilst 
the dressings are being changed, which must be often, by immersing 
the limb in a hot antiseptic lotion, carbolic (1 : 40), boroglyceride 
(1 : 20), corrosive sublimate (1 : 5000), for periods varying from ten 
minutes to two hours. 

After .separation of dead tissues, the granulating wound may be 
treated upon general surgical principles. 

Much care and attention must be given to the position of deep 
burns, so as to counteract the tendency to future deformity after cica- 
trization. 

The following are a few of the many other methods by which burns 
may be successfully treated. 

By enveloping the part in successive layers of gauze prepared by 
previously soaking muslin, freed from fatty matters, in an ethereal 
solution of iodoform, and allowing the ether to evaporate. This ap- 
pears to be a most excellent plan, and has given very satisfactory 
results in the hands of Mosetig, who has never seen any bad symp- 
toms follow. The free dusting with powdered iodoform of large tracts 
of the surface of the body involved in burns or scalds is dangerous. 

Oxide of zinc, or powered starch, may be dusted over burns instead 
of flour, and any harmless antiseptic may be combined with them. 

Of greasy applications there is no end. Chalk or whiting made into 
a paste with boiled linseed oil, calamine and zinc ointments made thin 
by adding olive oil, boric ointment, white lead paint, iodoform oint- 
ment (1 : 30 vaseline), carbolic oil (1 : 20), carbonate of zinc oint- 
ment (1 : 10 spermaceti ointment), resin ointment, chalk, olive oil, and 
vinegar in equal parts, cod-liver oil, kentish ointment (lin. tereb. U.S.P. 
resin ointment and turpentine). It is a good way to treat small super- 
ficial burns by applying turpentine as soon as possible upon lint ; 
though the pain is at first increased, it soon subsides. 

Salicylic oil (1 part acid to 60 olive oil). 

Olive oil and egg yolk, equal parts ; compound elemi ointment 
(B.P.) olive oil, and thymol (1 : 100). 

Of liquid applications for burns any antiseptic lotion may be used 
such as might be applied to ordinary wounds. (See under Abscess.) 
Solution of potas. permang. (1 : 500) is a good remedy in the early 
stage, and solution of cocaine (1 : 50) may be painted on to relieve 
acute pain. 

Of pastes the best are subcarbonate of bismuth and glycerin, oxide 
of zince and glycerin ; or powdered gum arabic, 3 parts ; tragacanth, 
1 part ; molasses, 2 parts ; carbolic acid lotion, q. s. 



98 BURSITIS — CANCER. 

BURSITIS. 

In acute affections following injuries and wounds, absolute rest of 
the limb on a padded splint, and the application of cold lotions or ice 
generally suffice to bring about resolution. If much pain be present, 
poultices smeared with extract of belladonna, or hot fomentations 
may be applied ; and if suppuration occur, a free incision and subse- 
quent syringing with very weak sublimate solution (1 : 5000) will be 
necessary. 

For the chronic affection most common in the bursa over the patella 
(housemaid's knee), the majority of cases yield to the daily application 
of strong iodine liniment, applied freely (as each layer is allowed to 
dry it may be followed by a fresh one), so that blistering occurs. 

Should this fail, the fluid may be aspirated, and if it soon collect 
again, a splint and tight bandage may be applied after a second 
aspiration. Should the fluid again collect, a few drops of strong 
carbolic acid may be injected, or the fluid once more removed, and a 
small syringeful of tincture of iodine and water (1 : 2) may be in- 
jected and allowed to remain in for a few minutes. 

A seton may be passed through the bursa, and allowed to remain. 
Melon seed bodies should be removed by small incisions, and the bursa 
flushed with weak sublimate solution. 

Chronic enlargement of the bursa, with fibroid thickening of its 
walls, can only be successfully treated by excision of the entire 
mass. 

CALCULI, Biliary— See Gall-stones. 
CALCULI, Renal — See Stone in the Kidney. 
CALCULI, Vesical — See Stone in the Bladder. 

CANCER. 

The treatment of the various forms of malignant disease by internal 
medication must be confined to the relief of pain, or to the ameliora- 
tion of symptoms caused by the disease interfering with the functions 
of the organs affected. 

The administration of Chian turpentine has not been followed by any 
success warranting further trial, and the same may be said of thuja, 
and in our present ignorance of the etiology of the malady, there is no 
internal remedy which can be said to have any effect upon the progress 
of the disease. 

All that we can say at present is, that early removal of the growth 
and surrounding tissues and lymphatics affords the only hope of cure, 
and though there are many who believe that operative interference or 
extirpation will after all but postpone the fatal issue, still there is 
abundant evidence that early and complete eradication of superficial 
malignant growths have been sometimes followed by immunity from 
any return of the disease, and when the disease has returned, it is 



CANCER. 99 

generally after such an interval as shows that its progress has been at 
least retarded. 

Extirpation by the knife, though it affords the best hopes, should 
not be solely relied upon, for one reason. There cannot be a doubt 
that the earlier the removal the better the prospects, and patients too 
often cannot be induced to submit to a cutting operation, even by the 
most urgent and earnest entreaties. In these cases radical application 
of arsenic, Vienna paste, chloride of zinc, caustic potash, pure bromine, 
papain, acid nitrate of mercury, or the thermo- or electro-cautery may 
give better results at a very early stage than can be obtained by the 
knife at a later period. The writer has seen this proved upon several 
occasions, where patients, refusing firmly to submit to a cutting opera- 
tion, have submitted to cauterization by arsenic at the hands of quacks 
with enviable results. The injection of acetic acid, nitrate of silver 
solution, carbolic acid, and solution of papain or pepsin into malignant 
tumors has led to no practical benefit. 

Mosetig-Moorhof's plan of injecting about a drachm of a solution of 
methyl-violet (1 : 500) is attracting deep interest. 

Cancer of the Bladder. — Removal of malignant tumors of the 
bladder should seldom, if ever, be attempted. Relief of pain by mor- 
phine, by the mouth, anus, subcutaneously, or by injection into the 
bladder, should be tried, and cocaine suppositories sometimes afford 
great relief, and injections of conium, chloral, and other sedatives occa- 
sionally give some ease. Failing this, however, a free perineal opening 
into the bladder, establishing thorough drainage, may give highly 
valued freedom from the agonizing attempts to micturate, and may 
enable the patient to pass the remainder of his short life in compara- 
tive peace. 

Cancer of the Breast. — The earliest possible removal of the 
whole gland, with exploration of the axilla and extirpation of every 
lymphatic gland to be seen or felt, is the only line of practice followed 
by satisfactory results. 

Heidenhain has made some remarkable observations, which empha- 
size the great importance of removing every vestige of the disease. He 
investigated histologically eighteen cases of primary cancer of the mam- 
mary gland. In all the cases in which there had been a recurrence, 
he was able to make out by microscopic examination that fragments of 
cancer had remained in the wound after the operation. The extension 
of the disease from the tumor to the surrounding tissues is invisible to 
the naked eye, and where he found no epithelial rays extending from 
the tumor to the margins of the tissues removed along with it, no return 
of the disease occurred. He often found that these extensions invaded 
the muscular aponeurosis of the pectoralis. Hence he insists upon 
the necessity of taking away the aponeurosis and cutting into the 
healthy muscle in every case where the tumor is adherent. 

Gross also puts this forcibly, when, after speaking of the old opera- 
tion as an opprobrium to surgery, he says — "All tissues — viz., the skin, 



100 CANCEE. 

para-inammary fat, the entire gland, pectoral fascia, and axillary con- 
tents — must be freely extirpated." 

Before the practice of clearing oat the contents of the axilla was 
generally followed, the writer traced every case of cancer of the breast 
which had been operated upon in a large hospital during two years in 
which he acted as resident surgeon, and he does not remember to have 
found one patient living eighteen months after the operation, the great 
majority having died long before this period. It should, however, be 
said that in most of these cases the disease had existed for a consider- 
able period before falling under the surgeon. The sponging out of the 
wound freely with strong solution of chloride of zinc or corrosive sub- 
limate should never be neglected before the sutures are put in. 

If the case be not one in which operation can be recommended when 
first coming under the attendant's notice, or if the patient refuses to 
submit to an operation, great care must be exercised in the use of local 
remedies for 'the relief of pain. Friction or irritants of any kind must 
be strongly condemned, and nothing that will hasten the breaking of 
the skin is to be permitted. If ulceration of the skin has already 
occurred, the application of any weak antiseptic lotion should be 
recommended. The application of caustics, like arsenic and others 
already mentioned, is to be avoided. 

Many substances may be now used with the view of lessening 
pain: 

Belladonna extract, rubbed up with glycerin. 

Hydrate of chloral (5 to 20 grains to 1 ounce). 

Carbolic acid lotion (1 : 30). 

Conium ointment (page 47). 

Cocaine solutions (1 to 5 per cent.). It may be used in the form of 
ointment. 

Galium aparine, hyoscyamus, belladonna, and stramonium leaves, 
made into infusion or decoction. 

Antipyrine (1 : 100) is recommended, but it often increases pain 
considerably. 

Fuchsine in alcohol (1 : 300) is recommended by Dyer. 

Morphine-vaseline, recommended by B. W. Bichardson, may be 
applied on lint wherever continuous pain accompanies the presence of 
a cancerous tumor. With an ulcerative breach of surface, the follow- 
ing is the formula ; the chloroform dissolves the alkaloid, is sedative 
and antiseptic : 

R . — Vaselini purif. ^j. 

Chloroformi gij. 

Morphiae gr. iv. — M. 

With the supervention of fetor, strong antiseptics are called for. 
Iodoform is the best, if its odor can be tolerated. It may be freely 



CANCER. 101 

dusted over the sloughing or ulcerated mass, or pads of iodoform gauze 
may be folded over the tumor. 

Bichloride of mercury (1 : 500 to 1 : 5000), powdered borax, boric 
acid or boroglyceride, salicylic acid in powder or the soda salt in 
strong solution, creasote, carbolic acid, thymol, oleum menth. pip., tur- 
pentine, terebene, aseptol, naphthol, pinus pumilio, permanganate of 
potash (1 grain to 1 ounce), zinci chlor. (10 grains to 1 ounce), and a 
host of other antiseptics, have been found useful. The best remedy, if 
the ulcerating mass be very extensive, is liberal and frequently changed 
pads of carbolic tow, or, should expense be a serious object, large pads 
of well teased out oakum, laid upon the surface of the tumor, and 
secured with a light bandage, affords the cheapest and most efficient 
dressing, without any lotions or other applications. 

Hemorrhage has to be sometimes treated, and, as the bleeding point 
is not easily seized in the midst of a fungating tumor, local hemostatic 
remedies must be applied. Should the hemorrhage be the result of 
general oozing, the application of some of the foregoing antiseptics, in 
concentrated form, will soon cause it to cease. Thus creasote, turpen- 
tine, or carbolic acid, smeared over the tumor, will relieve pain, check 
hemorrhage, and destroy fetor, powdered alum will do likewise. 

If the bleeding should be from a vessel of any considerable size — cut 
across by the ulcerative process — there is no hemostatic to be com- 
pared with the puff-ball — licoperdon giganteum. A small pad of the 
dried fungus placed over the bleeding surface, or thrust into any of the 
small ravines in the tumor from which blood is spouting or streaming, 
will almost instantly cause it to stop. (Pharmacy, Materia Medica and 
Therapeutics, fifth edition, page 581.) 

Cancer, Epithelial. — See rodent ulcer. 

Cancer of the Tongue. — Palliative measures are only justifiable 
when operative interference is out of the question. Cocaine dissolved 
in glycerin of borax (1 : 4), frequent applications of carbolic lotion 
(1 : 100), insufflations of boric acid, or the application of powdered 
iodoform and bismuth (1 : 10) to any deep ulcers, and the use of 
deodorizing solutions may be tried. 

Extraction of teeth which press upon the enlarged organ, and, in 
some cases, the section of the gustatory nerve will be required. Liga- 
ture of the lingual artery has been done to diminish the rate of 
growth. 

When possible, complete removal of the organ should be attempted, 
unless when the disease is in a very early stage and confineol to the 
anterior part of the organ, when the tumor may be removed by the 
knife, scissors, or ecraseur. 

(For a brief description of the operations for removal of the entire 
organ, see under Tongue, Diseases of.) 

Cancer of the Gullet. — Where ulceration has not already 
occurred, considerable relief will be obtained by the careful and gentle 
passing of a tapering or olivary bougie. The slightest pressure may 



102 CANCEE. 

rupture the tube above the obstructing mass, and only the most cau- 
tious and tender handling of the dilating instrument is admissible. 
Good results have followed this palliative treatment when the bougie 
has been left in- situ for hours, and if the instrument be hollow, it may 
be returned in the stricture whilst the food is passed through it into 
the stomach. The writer used bougies made of laminaria in the treat- 
ment of non-malignant stricture of the gullet as early as 1875 with 
success. 

When the passage of food through the narrow and irritated stricture 
becomes impossible, rectal feeding should be persisted in. Enemata of 
raw eggs, peptonized food or milk, or milk pancreatized may be given 
every few hours, and the sensibility of the rectum blunted by the 
addition of a small quantity of laudanum to each. 

In a limited number of cases where an opening was made by the 
surgeon into the stomach through the abdominal walls, great relief 
and some prolongation of life has been the result. This has been of 
late years done very successfully by adopting Howse's method. An 
oblique incision, two and a half inches long, is made parallel with the 
margin of the left costal arch, the sheath of the rectus is opened by 
a vertical incision and the fibres separated with the handle of the 
scalpel ; the coats of the stomach are made to bulge into the incision, 
and are fixed to the abdominal walls by a double row of sutures tied 
over a piece of catheter, and the whole left in situ for four or six days, 
after which a small opening into the stomach is made by a" sharp 
tenotomy knife, a catheter is inserted, and food injected through it. 
The opening in the stomach is gradually dilated with bougies, so as to 
admit a good sized rubber tube for feeding purposes. 

Cancer of Stomach. — The treatment of this grave malady will 
chiefly resolve itself into the selection of suitable food, and the relief 
of the various symptoms arising from the pyloric obstruction so com- 
monly present. Should the malignant disease occupy the cardiac end 
of the stomach the management of the case will be the same as if one 
of cancer of the gullet; should the body of the stomach be involved 
the treatment will be upon the same lines as if a simple ulcer existed. 

The diet should be of the most nutritious kind possible; at the same 
time only such food should be given as will be quickly digested in the 
stomach, or will rapidly find its way through into the intestines. Strong 
soups strained from all solid particles, concentrated beef essences and 
juices, thickened with fine farinaceous foods, and milk in unlimited 
quantity, must form the chief basis of the dietary. In advanced cases, 
rectal alimentation should be resorted to. The secret of success in this 
class of cases is to feed continually, but in very small quantity. It is 
not a very unusual experience to come across cases of cancer or ulcer 
of the stomach, where incessant, painful vomiting has brought the 
patient to a. miserable state of collapse, through the ingestion of even 
moderate quantities of solid or liquid food. If the physician orders 
a diet of soup and milk, or peptonized milk, to be given in such a 



CANCER. 103 

case in unlimited quantity, making it a stipulation that only one large 
spoonful be given at one time, the liquid will pass directly through 
the stomach into the intestines, and all vomiting and much suffering 
will stop. 

These directions must be literally carried out. It will not do for 
the patient to take in his hand a vessel of liquid food out of which he 
is to drink what he considers will about amount to a tablespoonful. 
The food must be measured in a spoon as if it were medicine. 

Stimulants in liberal quantity need not be withheld, as they help 
the patient materially, and owing to the comparatively short duration 
and invariably fatal termination of the affection, the alcohol habit 
need not be dreaded. 

The best stimulant is good whiskey or brandy mixed with the milk 
(1 to 10). Wines, as a rule, intensify the acidity often present, though 
good champagne is of great use in the vomiting of the latter stages of 
the disease. 

In some cases where the pyloric symptoms and signs are well 
marked, careful washing out of the stomach by the pump and an 
India-rubber tube is often followed by great relief. For the treat- 
ment of pain and vomiting see under Gastric Ulcer, where the various 
agents used for this purpose are detailed, but the chief reliance is to 
be placed in bismuth, combined with morphine and hydrocyanic acid, 
ice, and counter-irritation. 

Digestives, like pepsin and papain, are indicated where there is no 
reason to believe that an ulcerating surface exists in the mucous mem- 
brane. Where there is marked deficiency of free hydrochloric acid 
in the stomach, this drug can be supplied with pepsin. 

The vomiting of acid and yeasty matters is best met by creasote ; 
one to three capsules (1 minim each) may be given three or four times 
a day. Hyposulphites, sulphurous acid, eucalyptus, and carbolic acid 
may be given with a view to destroy the sarcinse in those cases where 
there is evidence that the food is detained so long as to undergo 
fermentative changes. Constipation, sleeplessness, and other com- 
plications are to be treated upon general principles. Ascites, peritonitis, 
jaundice, Or secondary hepatic derangements are also to be watched 
for. 

The operation of removal of the pylorus has been performed at 
least one hundred times, and in many cases with marked relief and 
considerable prolongation of life. It is justified as a radical measure 
by at least one strong consideration — i. e., that cancer of the pylorus 
may exist for a very considerable period without any extension of the 
disease to lymphatics or neighboring parts ; and the history of the 
operation shows that if the shock be got over, the patient may possi- 
bly live for three or four years afterward. 

The pyloric tumor is drawn out of a wound four to five inches long, 
made by an oblique incision parallel to the right costal margin. After 
separation of the omentum, the mass is removed, and the cut ends of 



104 CANCER. 

the stomach and duodenum secured together by Ozerny's sutures, and 
returned to the abdominal cavity. 

Woelfler has successfully performed the operation of gastroenter- 
ostomy, by which, after exposure of the pyloric tumor and adjacent 
stomach and duodenum, an incision is made into the free border of 
the latter beyond the pyloric obstruction, and the lips of the incision 
are stitched to the lips of a similar incision made in the coats of the 
stomach near to the pyloric end. No interference takes place with the 
tumor. The food passes directly from the stomach into the small 
intestine, though the pylorus is blocked up. 

Duodenostomy and jejunostomy, by which an attempt has been made 
to establish permanent artificial openings through the abdominal parie- 
ties into the small intestine in cases of pyloric cancer, have not been 
followed by results warranting further trial. 

Fischer reported a few years ago to the German Congress a case of 
resection of the stomach. A tumor was felt, which, upon opening the 
abdomen, was found to be situated upon the great curvature of the 
stomach. A large portion of the stomach was removed successfully, 
and in seven days the patient was able to take her nourishment by the 
mouth. She succumbed five months 'afterward to a perforating ulcer 
of the stomach. The cicatrix of the incision could not be discovered, 
such perfect union having taken place. 

Cancer of Intestines. — This generally causes death by obstruct- 
ing the bowel, hence by dietetic treatment much can be done to pro- 
long life by selecting foods which leave the least indigestible residue. 
Laxatives, like cascara, sulphur, olive oil, or cod-liver oil, should be 
employed to keep the motions soft, and feeding by the bowel should be 
commenced early. 

Enterectomy in certain cases affords great relief and prolongs life. 
The portion of bowel, the seat of cancer, is drawn out through an 
incision in the middle line below the umbilicus, and the diseased por- 
tion excised with scissors, the divided ends of the bowel brought into 
apposition and sutured with two distinct sets of sutures, one passing 
through the mucous coat alone (about fifteen in number). The serous 
coats are next fastened by about twenty-five separate sutures, and the 
whole returned within the abdominal cavity, which is then closed in 
the usual way. It is, however, found best to stitch the divided ends of 
the bowel to the skin wound, so as to produce an artificial anus, which, 
after a time, can be closed by a further resection, approximation, and 
suturing of the divided ends, and their final replacement in the 
abdomen. 

The operation of enterotomy may be done, by which an incision in 
the right inguinal region into the abdomen permits the surgeon to open 
the first distended coil of intestine which bulges into the wound. This 
method is applicable to grave cases where one is not justified in per- 
forming enterectomy. The distended coil protruding into the abdomi- 
nal wound is sutured to the lips of the incision, after which the bowel 



CANCER. 105 

is freely opened between the two lines of sutures, and an artificial anus 
maintained. 

Cancer of the large intestine, leading to obstruction of the bowel, is 
best relieved by lumbar colotomy. Amussat's operation of opening 
the colon, either in the left or right loin and permanently establishing 
an artificial anus, is the one most commonly indicated. 

Cancer of the Liver, hitherto regarded as beyond the reach of 
surgery, has been quite recently treated by excision. Lxicke, after 
opening the abdomen, excised a cancerous mass situated in the left lobe 
by drawing it through the abdominal wound, and fixing it there by 
sutures, the excision being performed by the slow pressure of the elastic 
ligature. Recovery was rapid, the patient leaving hospital in four 
weeks. 

Cancer of Rectum can only be treated satisfactorily by excision 
of the diseased portion of the gut, and most satisfactory results may be 
obtained even in cases where " obstruction " symptoms have been well- 
marked, provided the disease is within easy reach of the finger, and 
there is no infiltration into surrounding tissues, and the rectum is quite 
movable. The whole or a portion of the rectum may be removed. 
Though the operation is a very formidable one, a good recovery often 
ensues. Cripps emphasizes the important statement that not more than 
15 to 20 per cent, of cases which present themselves are suitable for 
operation. He insists that no operation should be undertaken, unless 
there is a reasonable prospect of being able to make a thorough removal 
of the whole distance. Under ordinary circumstances the finger can 
explore to a distance of from four to five inches from the anus. If the 
finger can pass sufficiently beyond the disease to feel a healthy mucous 
membrane, so far as the height is concerned a satisfactory removal is 
possible. It is, moreover, essential that the finger should determine 
that the rectum is movable and free, and that no infiltration into sur- 
rounding organs has occurred. 

The writer had a case under observation where, after symptoms of 
obstruction had existed for several weeks, excision of a large portion — 
three inches of strictured bowel — was most successfully performed by 
Mr. Cripps nearly four years ago. The patient is still living, and most 
marked relief and great increase in body weight followed. Two years 
after the operation there was no sign of a return, and the writer believes 
there is no return, though he has not seen the patient for a considerable 
time. 

F. Marsh advocates a preliminary colotomy or colectomy in all cases 
in which a proctectomy (excision of the rectum) is to be undertaken. 
Mitchell Banks, who prefers lumbar to inguinal colotomy, instead of 
merely opening the colon laterally, and stitching the lateral orifice to 
the wound, cuts the bowel clean across, and fixes the upper end. This 
he considers a necessary preliminary to proctectomy or excision of the 
rectum. 

If the stricture is beyond the reach of the finger, and there be evi- 

8 



106 CANCER. 

dence of infiltration of uterus or bladder, lumbar colotomy is the only 
palliative treatment when obstruction has set in, but if the disease is so 
extensive as to lead the surgeon to believe that it will very soon cause 
the death of the patient apart from the obstruction, even colotomy is 
not justifiable. Enterotomy may, under such circumstances, be allow- 
able. 

Cancer of Uterus. — The indications requiring treatment are pain, 
hemorrhage, and fetor. The only satisfactory treatment is removal of 
the disease when this is possible. 

The general health of the patient should be attended to, diet unlim- 
ited, and moderate amount of stimulants in the later, stages. The 
patient, if confined to bed, should be placed in the upper room, with a 
sunny aspect and good ventilation. The air of the apartment should 
he kept sweet with terebene, or any fragrant pine product. Sawdust 
sprinkled with oil of turpentine is a good disinfectant, and is not sug- 
gestive. The bowels should be kept natural with a laxative like cas- 
cara, or sulphur, or by enemata of tepid water. 

Pain will be best relieved by morphine or opium in the form of 
suppository. It is a mistake to begin with hypodermic injections; \ 
grain by bowel, or 1 grain of opium by the mouth, will generally be suf- 
ficient to lull pain at first, but at a later stage often large doses are 
required hypodermically. Medical pessaries are not so satisfactory as 
suppositories. 

Fetor is best met by thorough cleanliness and good nursing. Anti- 
septic injections : borax in saturated solution, carbolic acid (1 ounce 
to 3 pints), bromine (1 : 500), acetate of lead (1 ounce to 1 gallon), 
permanganate of potash (5 grains to 20 ounces), bichloride of mercury 
(2 grains to 1 pint), creolin (1 : 20) may be employed. 

Cheron recommends the following deodorizing injection: 

R. — Acid, salicylic gr. viij. 

Sodii salicylat. giij. 

Tinct. eucalypt. gvj. 

Aquse destillatse t ^vj. — M. 

S. — Three tablespoonfuls to be added to one or two pints of water, and used 
as a douche every three or four hours. 

The effect of these injections is but temporary, and their disinfect- 
ing or deodorizing qualities last but a very short time — a matter often 
of minutes — and it is necessary to leave some more concentrated prepa- 
ration in the vagina to prevent the patient becoming a burden to 
herself and her friends. 

Iodoform is the most powerful of all remedies. Pledgets of cotton 
wool or lint, soaked in a mixture of iodoform, rubbed up with glyce- 
rin, destroy all trace of odor. 1 : 40, or in bad cases 1 : 8, may be 
employed, and left in the vagina all night. 



CANCER. 107 

Playfair uses in a similar way a mixture of 1 ounce glycerin of 
carbolic acid and 8 ounces glycerin of tannic acid. 

Betrin uses tampoons soaked in equal parts of terebene and almond 
or olive oil, after an abundant preliminary douche of Condy's fluid 
and water. 

Oil of turpentine, shaken up with water (1 : 100), may be used as 
an injection, or mixed with olive oil (1 : 4), it may be applied on 
tampoons. 

Packing the vagina with powdered boric acid is a good plan. The 
plugs should be removed twice a day, and the vagina well syringed 
with any of the above lotions each time. 

Hemorrhage is best checked by local applications or plugging of the 
vagina ; hemostatic remedies by the stomach are not to be depended 
upon. Should the bleeding be alarming, plugging must be resorted 
to, and if from the body of the uterus, the os being dilated, strong 
chloride of iron solution (1 : 4) may be injected. Cold saturated solu- 
tion of alum answers well in most cases. If the source of the hemor- 
rhage be within reach and visible, the bleeding point may be touched 
with any strong caustic, as concentrated liq. ferri chlor., or a minute 
pledget of lint soaked in it may be left in contact, and the vagina 
plugged with wool soaked in weak carbolized oil (1 : 20). The writer's 
however, never uses carbolic acid where there is a distinct fetor ; the 
combination of the odor of the acid with the fetor makes generally a 
new volatile compound of still more disgusting smell. Chloride of 
zine freely applied to the bleeding spot is the mest reliable of all 
applications ; it also checks the disease by destroying the growth. 

The galvano- or thermo-cautery may be employed ; if the hemor- 
rhage recurs the bleeding surface may be thoroughly scraped with the 
curette. The puff-ball may be pushed through the speculum and left 
in situ as a plug in severe cases. Ice may be also useful sometimes, and 
it has the advantage of being easily used by the patient. 

A powerful continuous current (Apostolus method) is effective. 

The surgical treatment of uterine cancer will depend upon the por- 
tion of the uterus invaded. The epithelial growths springing from 
the os and cervix may 'be removed, in some instances completely, with- 
out interfering with the body of the uterus. Caustics — potash, and 
zinc chloride, arsenic, alcoholic solution of bromine (1 : 5), strong 
nitric and carbolic acids — are used, but seldom good results follow. 
Often the inflammatory action following their irritant action gives a 
fillip to the disease. The three first on the list just mentioned may 
eat their way through diseased tissue, but unless applied with great 
skill and care their action cannot then be stopped, and the danger is 
thus so great that their use is to be condemned as a routine method. 
The remaining members on the list are too superficial in their action 
to be of any permanent benefit. 

If chloride of zinc be used by Braithwaite's method, excellent 
results may be obtained in selected cases. He takes the fluid resulting 



108 CANCER. 

from the deliquescence of the solid zinc chloride, thin layers of cotton- 
wool are wetted in this saturated solution, and the superfluous moisture 
is removed by lightly pressing them between sheets of blotting-paper. 
These are applied for twenty-four hours, the healthy parts being pro- 
tected by tampoons soaked in soda solution. By care and the re-appli- 
cation of the caustic the disease may be destroyed to any depth. The 
healing process afterwards is followed by great contraction and pucker- 
ing of the parts. 

Scraping away of the diseased surface by means of Simon's sharp 
spoon, or by the ordinary curette, is a much better partial operation 
than the destruction of the tissue by caustics. After all the diseased 
growth is thus removed down into the sound tissue by Arm scraping, 
the cautery is applied, and a still further layer destroyed, or caustics 
may be used with much advantage. 

Curetting may be combined to great advantage with chloride of 
zinc. After all the diseased tissue has been thoroughly removed by 
the spoon, cotton-wool damped in saturated solution of the caustic may 
be thoroughly applied to the raw surface to destroy rays of cancerous 
growth which escape. Many practical operators prefer this method to 
the cautery or knife. The writer has" several times employed it, and 
watched its effects in the hands of others, and believes that it is the 
best of the partial methods of dealing with uterine cancer. 

Amputation of the cervix by the knife or scissors, and stitching 
together of the mucous membrane over the wound, or the insertion 01 
deep sutures into « the incised lips of the cervix after the removal of a 
wedge-shaped mass of malignant tissue, is also followed by good results 
in a fair proportion of cases at the early stage. The entire cervix may 
be amputated. Marion Sims applied strong cautics after these partial 
operations. Chloride of zinc (1:1 or 1 : 2 of water) is applied upon 
plugs of lint three or four days after the amputation, and left in situ 
for one or more days, the vagina being protected by tampoons of 
cotton-wool soaked in saturated solution of soda? bicarb. 

Schroeder has applied the actual cautery freely after cervical 
amputation with satisfactory results. 

Where the disease has attacked the cervix high up, or the body of 
the uterus, the entire organ should be excised (hysterectomy). 
Freund's method of accomplishing this by abdominal incision, has 
largely given way to Schroeder's or Billroth's plan of removing the 
uterus through the vagina, and many cases of long immunity have 
followed the operation, though in cervical cancer there does not appear, 
to many operators, to be any advantage in removing the entire organ 
if the disease can be got away by amputating the cervix, as is 
generally the case. 

T. Keith, after much experience, states that he never would hesitate 
between the partial and complete removal, as there may be cancerous 
nests in 'every fundus, though the disease may seem quite localized. 
He performs vaginal hysterectomy with scissors, and has never lost a 



CANCRUM ORIS. 109 

case from hemorrhage. This latter complication is more likely, in his 
opinion, to follow the use of the cautery, as its action must be incom- 
plete. 

Upon the other hand, Byrne states that he has operated upon 367 
cases of uterine cancer with the galvano-cautery, and the. average 
period of exemption iu known cases was eight years and seven months. 
He amputates the cervix with the loop, and cauterizes the mucous 
membrane of the uterus and the stump by an instrument passed into 
the cavity. Notwithstanding the fact that cancer of the cervix tends 
not to pass upwards into the uterus, but to spread into the surrounding 
tissues upon its return in the stump, the total operation is steadily 
gaining ground in this country, and upon the Continent it is nearly 
always preferred to the partial operation. Zucker Kandl removes the 
uterus from a perineal incision, and Kraske resects one sacral wing 
along with the coccyx. 

CANORUM ORIS. 

Constitutional treatment is of great importance in this formidable 
affection. Nutritious diet, with stimulants, free ventilation, and 
everything that can improve the general condition of the ill-fed and 
badly cared-for child must be insisted upon, but no time is to be lost 
in resorting to the only local treatment available, i. e., the free appli- 
cation of powerful caustics to the sloughing spot. Strong nitric acid 
is far the best remedy, and it should be applied, under chloroform, 
after the inside of the cheek is exposed and wiped dry, care being 
taken to prevent the acid finding its way to the healthy surrounding 
mucous membrane. Poultices may be applied externally ; but if a 
gangrenous patch is visible externally, it should be cut or scraped out, 
and the strong acid applied freely to the margins of the hole. 

Stephen Paget recommends that desperate cases should be promptly 
treated by excision of the slough and surrounding ring of healthy 
tissue by the knife, Trousseau applied the actual cautery. 

In mild cases weak corrosive sublimate solutions may be used, and 
even in severe cases speedy recovery has followed their use. Gates 
and Kingsford report success in three cases, by cutting away all 
sloughing masses and swabbing the ulcerated surfaces once or more 
daily with a 1 : 500 bichloride of mercury solution, whilst a 1 : 1000 
solution was kept constantly applied. Healthy granulations soon 
appeared, and recovery was rapid. 

Ammonia and cinchona, with stimulants, must be pushed, and if 
concentrated beef essences and soups cannot be swallowed, they should 
be given by the bowel or by the nasal tube. The local after-treatment 
will consist of free applications of chlorate of potassium, dusted in 
fine powder over the sore, or the mouth and check may be syringed 
with a solution of the drug (1 : 50) several times daily. The most 
rigid cleanliness is essential, and the syringe should be used almost 



110 CARBUNCLE. 

constantly at first. Iron must be given internally, and the most liberal 
feeding kept up for a long period, The resulting deformity may be 
remedied afterward to some extent by operation. 

CARBOLIC ACID POISONING— See under Poisoning. 
CARBUNCLE. 

In the management of this affection a generous diet, with stimulants, 
and, if possible, open air walks or drives are essential. Iron, inter- 
nally, in doses of 15 minims of the tincture with 2 or 3 grains quinine 
four times daily, should be given from the beginnings with saline 
purges every second morning. Sulphide of calcium in i grain 
doses every two hours has been used to influence the suppurative 
process, and arsenic is useful in chronic cases. If great prostration 
be present, a mixture of 2 ounces spt. amnion, aromat. and 2 ounces 
tinct. cinchonas may be given in doses of a large teaspoonful with 
a tablespoonful of brandy in a wineglassful of water every two hours. 
Opiates, or antipyrine may be given to relieve pain and to assist sleep. 
Local treatment should consist of a free crucial incision across the 
face of the carbuncle, through skin and slough down to the healthy 
tissues beneath. A hot poultice, rendered antiseptic by a coating of 
boric or iodoform ointment, should be applied, but constant poulticing 
is to be avoided after the early stages. 

All the benefits of a poultice during the healing stage may be 
obtained by any antiseptic lotion on lint, covered with oiled silk, and 
upon the top of w T hich a pad of cotton- wool is fixed with a bandage or 
strapping. 

Carbolic acid is injected into the slough by some surgeons without 
making the crucial incision. Recently this treatment has been modi- 
fied by diluting the acid and injecting small quantities (about 1 drachm 
in all) into different parts of the tumor. The following is the usual 
formula, and excellent results are reported : 

R . — Acid, carbol. pur gj. 

Glycerin, purificat 5 v. 

Aqua? destillatre 3 v. — M. 

The writer, after making the two deep incisions at right angles to 
each other, thrusts deeply into the slough at two or more points a 
piece of lint wrapped around a stout director and dipped in the strong- 
est carbolic acid. 

It is a good practice in some cases to push in small fragments of 
caustic potash through the openings in the carbuncle. 

Lately splendid results have been obtained by playing the spray of 
a carbolic acid lotion (1:50) upon the carbuncle for about fifteen to 
twenty minutes every four hours, and avoiding incisions. This treat- 
ment can be combined with incising or using caustics or poultices. 



CARIES. Ill 

Strapping, by firmly getting a good hold upon the healthy tissues 
on each side, hastens the discharge of the slough and gives great relief, 
a fair opening being left in the centre of the plaster for the drainage 
of all discharge. 

The old expectant treatment, by poulticing and hot fomentations, is 
tedious, aud favors blood poisoning, and the method of applying weak 
iodine under compresses is also of little use in most cases. Pain may 
be relieved by applications of extract of belladonna rubbed up with 
glycerin, and smeared over the part, or applied upon the surface of 
the poultice. Cocaine solution, 2 per cent., may be applied upon oiled 
silk, or chloral solution (5 grains to 1 ounce) is a good lotion at a 
later stage. 

Blistering, arnica, collodion, and mercurial ointment, have been 
advocated ; but the free incisions, followed by poulticing and antisep- 
tics, afford best results. 

Ether, sprayed upon the slough, is said to hasten its removal. 

Recently, Teale and Page have reported cases where " scraping " 
was performed by a Volkmann's spoon or Lister's scraper with great 
success. After a crucial incision, the slough is thoroughly scraped out, 
the cavity washed with an antiseptic, and the wound dressed with 
iodoform. 

Should there be much fetor, sublimate solution (1 : 5000), or tur- 
pentine, or terebene, or syringing with solution of chlorinated soda (1 
drachm to 1 ounce), or Condy's fluid and water may be employed. 
Iodine liniment, very freely painted round the base, gives relief, and 
subdues pain caused by congestion in the surrounding healthy tissues 
after the carbuncle has been incised. 

The severe form of carbuncle attacking the face, must be treated 
upon the same general lines — supporting diet and stimulants, free in- 
cisions and antiseptics. 

CARCINOMA— See Cancer, page 98. 

CARIES. 

Bone caries being, in the great majority of cases, a local manifesta- 
tion of struma or tubercle, constitutional treatment is of the greatest 
importance, and there can be no more serious mistake made by the 
surgeon, than to confine his efforts to the local management of the 
case. The best treatment is that indicated in strumous affections : Cod 
liver oil and malt extract ; milk in large quantities ; the removal of 
the patient to a seaside place sheltered from east winds and protected 
from the north; iodides (chiefly ferri iod.), phosphates, hypophos- 
phites, calcium chloride, gold and barium salts, and other remedies 
mentioned under scrofula and tuberculosis. 

Local treatment will vary with the anatomical position of the bone 
affected. If in the proximity of a joint, rest must be insisted upon, 



112 CARIES. 

and this should, if possible, be supplemented by the application of a 
splint, or immovable apparatus, which will enable the patient to spend 
the greater portion of his time in the open air. It is a serious matter 
when patients, the subject of bone caries, are sent to bed, especially in 
crowded cities. 

Where matter is pointing, a good deep and free incision into the 
bone, through all intervening tissues, is desirable, and, if the case be 
a chronic one in which partial drainage has been established by nature, 
it will be wise to plan the incision so as to take in any old sinuses 
that may be within its sweep. Poulticing,, except to allay pain and 
tension, should be avoided. The free use of antiseptic solutions, as 
hydrarg. bichlor. (1:5000); carbolic acid (see under Abscess) is far 
better. The sinus or wound may be frequently syringed out with any 
such lotion, and then covered with lint soaked in it, and a piece of 
oiled silk laid over all. A drainage-tube should be left in situ if the 
wound or sinus be deep. 

Various methods of treating the disease, by injecting substances 
into the sinuses, have been advocated. The writer has seen excellent 
results from the injection of the undiluted compound tincture of ben- 
zoin, as practised by the late Professdr Gordon. Pollock advises the 
injection of strong sulphuric acid and water in equal quantities ; the 
strength of the acid to be gradually increased until it is injected pure. 

Red precipitate upon a moistened probe was an old method of set- 
ting up new action in the sinus and bone. 

Turpentine, caustic potash (liquefied), tincture of iodine, Villate's 
solution (zinc and copper sulphates, liq. plumbi, and vinegar), and 
many other compounds have been used for the same purpose with 
vary success. 

If the carious bone is easily reached, strong caustics — as caustic 
potash, chloride of zinc, or the actual cautery — may be freely applied 
to the carious cavity after a free incision through the skin. The bone 
may be entirely excised, which is the best treatment for the small 
bones or os calcis, when extensively diseased. 

The great surgical procedure is gouging, and it was the invariable 
rule to make an early incision, retract the lips of the wound, dissect 
down to the bone, and gouge away as much softened bone as possible, 
wash out the wound, and allow the cavity to granulate, and often 
rapid cures occurred. The very class of cases benefited most by this 
treatment will also get well without it, and the operation of gouging 
should not be . lightly undertaken until every other means has been 
tried. The cavity left in the healthy bone should be well swilled out 
with strong carbolic lotion, bichloride solution (1 : 500), chloride of 
zinc (1 : 15), and packed with lint saturated with any antiseptic solu- 
tion or with iodoform gauze, and dressed in the usual way. After a 
few days the lint should be withdrawn, and the cavity syringed out 
twice a day with antiseptic solutions. 

See under tuberculosis for an account of Koch's method, and for 



CARIES OF SPINE. 113 

the still more recent plan of Lannelongue by injecting chloride of zinc 
into the surrounding tissues. (See also under Necrosis.) 

CARIES OF SPINE. 

Belonging to the strumous group, this affection can only be treated 
by thoroughly constitutional measures, supplemented by local appli- 
ances and rest, cod-liver oil, with malt extracts, iodide of iron, hypo- 
phosphites, and the various remedies applicable in wasting diseases 
and tubercle or struma (which see), liberal diet of peptonized milk 
with koumiss (page 23), and beef juices or meat jellies. Open air 
when possible, and change to a sheltered seaside spot, with cheerful 
surroundings, should be advised. 

In the early stages of the disease, where the diagnosis is based upon 
neuralgic pains or numbness in the legs and other symptoms before 
there is any local deformity, absolute rest in bed or upon a hard mat- 
tress in the open air is essential. This treatment must be insisted upon 
for months. Local pain or tenderness over the spinous processes of 
one or more vertebrae, at this early stage of the affection, my be re- 
lieved by couter-irritation. Strong liniment of iodine may first be 
tried ; should it fail to give relief, blisters may be tried. They should 
be small, and only kept on for two or three hours, and then appliod 
every three or four days. It is advisable not to break the skin, as the 
best position for the patient is to lie flat upon the back, which would 
be impossible with open sores over the spine. 

In adults, the application of Corrigan's iron gives relief. The in- 
sertion of issues and the painful use of moxas are deservedly passing 
out of date, as is also the questionable practice of leeching. 

In mild cases pain is often relieved by wearing a piece of silk soaked 
in liniment of chloroform, and covered over with oiled silk. When 
the acute symptoms have passed away, and the patient begins to feel 
the recumbent posture irksome, the time has come for the application 
of some mechanism whereby the weight of the upper part of the body 
may be taken off the diseased vertebrae. Where the lesion is located 
in the last one or two dorsal and first or second lumbar segments (by 
far the most common region), the application of a plaster jacket is by 
far the best appliance. The plaster jacket, however, will do nothing 
which prolonged rest in the recumbent position will not achieve, but 
the disease being one in which the general health and constitutional 
vigor of the patient are seriously impaired by many months or years 
in bed, it is a matter of immense importance if the same rest can be 
given to the diseased spot while the patient enjoys an outdoor life, ac- 
companied by exercise and change of scene. 

In very young children the situation is different. They can be car- 
ried or wheeled about while in the lying posture, and have all the ad- 
vantages of open air and change of scene. 

To apply the jacket, the patient should be stripped of all clothing 



114 CARIES OF SPINE. 

and a neatly-fitting woven merino vest, without buttons, should be put 
on. It should reach below the buttocks. He is then suspended by 
the usual pulley and cord appliance, by means of a strap passing 
below the chin and occiput, and another under each armpit. It is not 
generally necessary to raise him entirely off the ground ; for nearly all 
purposes his toes may be left touching, as it gives confidence to him, 
and if absolutely complete extension be needed, by flexing the knees 
very slightly the toes will, of course, leave the ground. 

The vest is pulled gently downward and all wrinkles removed, and 
a pad placed inside it over the pit of the stomach. This is to be slipped 
out afterward, its object being to leave room for distension of the 
abdomen after meals. Coarse muslin bandages, thickly sprinkled over 
with dry plaster-of-Paris, are to be rapidly immersed in cold water, 
slightly squeezed out, and applied over the vest in layers, extending 
from about an inch below the iliac spines to the armpits. An assistant 
smoothes down each layer of bandage as it encircles the trunk, and, 
from time to time, applies with his hand some more plaster, made into 
a cream with water ; or, if the bandage appears to have been too well 
moistened, he rubs over it a little dry plaster as the operation pro- 
ceeds. 

For small children, three inch bandages three yards long will answer ; 
four or six of these may be used. Adults require longer and broader 
bandages, and a larger number of them. 

Should the patient be thin, small pads of wadding may be placed 
over any bony prominences outside the vest before the application of 
the first bandage, which may be passed around the pelvis and brought 
obliquely upward as it encircles the abdomen, fixing permanently in 
their position all woolen pads over the iliac spines or prominent verte- 
brae. After the application of the last bandage, the assistant applies 
some fresh plaster, rubs it down with his hand, and finishes the jacket 
off, leaving a smooth and even surface. It sets in a few moments, and 
the patient may be taken down and laid flat upon a hard mattress 
before the fire for a short time before being carried to bed, from which 
he may get up next morning and run about. By turning up the tails 
of the merino vest over the plaster, near the end of the operation, a 
more presentable finish off is obtained. The jacket may be worn for 
two months or more, and may be cut up, punched with holes, and 
laced on again, if found quite satisfactory. In this latter case it can 
be taken off at night. Several jackets may be applied during the 
course of the disease. 

When consolidation has advanced to a considerable degree, the 
plaster of Paris jacket may be replaced by one made by poroplastic 
felt. Jackets ready-made, of various sizes and shapes, may be obtained 
from any instrument maker, and rapidly adjusted to the patient's body 
when suspended. The felt jacket is put into an ordinary range oven, 
and, in a few minutes, it becomes quite soft and pliable, in which con- 
dition it is moulded to the chest and abdomen, fastened with buckles, 



CATALEPSY. 115 

and the setting process is complete in five to ten minutes, during 
which time the suspension is to be kept up. It can, every four or six 
weeks, be re-heated and applied again, as it yields a little with the heat 
of the patient's body. Some cases of spinal caries, in weak and thin 
subjects, can be treated in this way from the first. It has the great 
advantage of being easily taken off and put on, and allows of daily 
inspections if abscesses are feared. 

In disease of the highest cervical vertebrae, the patient must be laid 
upon his back, with the neck fixed in a comfortable position with 
pillows and sandbags, as long as any acute symptoms are present. 
Afterwards, a modification of the plaster jacket may be applied, carry- 
ing narrow plaster bandages around the forehead, over the ears and 
occiput, and under the armpits. 

In disease of the lower cervical segments, Sayre's jury-mast appa- 
ratus should be applied. It may be adjusted in connection with a 
poroplastic instead of a plaster of Paris jacket. 

Hadra has suggested the heroic procedure of wiring of the vertebra? 
after other measures, such as trephining of the vertebral arches, etc., 
had failed. 

(See under tuberculosis for the details of Koch's method of treating 
of tuberculosis in bone.) 

Lannelongue's new method of treating osteo-arthritis and caries, 
by deep injections of the chloride of zinc, will be also found detailed 
under tuberculosis. 

CATALEPSY. 

The treatment of this condition means generally the treatment of 
hysteria, of which it may, however, be the only symptom. If there 
be loss of consciousness associated with the muscular rigidity, the 
patient should be aroused by a good dash of cold water thrown suddenly 
over the head and face. Should this fail, a smart electric shock from 
a frictional machine, or what is much more convenient, a pretty severe 
induced current may be passed through the arms. It should be sud- 
denly applied in full strength, and not turned on gradually. One 
pole may be applied to the upper part of the spine, and the other to 
the rigid limb. Gowers states that a pinch of snuff may soon restore 
consciousness. Emetics often dispel all symptoms, but the patient is 
either unwilling or unable to swallow them, and it is best to administer 
Y 1 ^ grain apomorphine hypodermically. After the attack passes off, 
drachm doses of the ammoniated tincture of valerian, with a little 
asafcetida, have a good moral influence. Should there be a very dis- 
tinct series of attacks, the removal of the patient from her surround- 
ings and a good course of massage and forced feeding will prevent a 
return. 

Cannabis indica in small doses (5 to 10 minims of the tincture) 
is said to give good results, though the rationale of its action is obscure, 



116 CATARACT. 

and the general objections to all narcotics in affections of this sort 
must not be forgotten. 

CATARACT. 

The only satisfactory treatment is operation. In the early stages of 
nuclear cataract, smoked or dark glasses give some relief by favoring 
dilatation of the pupil, and the sight may be much improved by 
keeping up moderate dilatation by using an ointment consisting of -§- 
grain atropine, and 4 drachms vaseline, 

Operations are of various kinds: 1. The removal of the lens 
entire through a large corneal or sclero-corneal wound, leaving the 
capsule behind. 2. The removal of the lens in a similar way along 
with the capsule. 3. By causing absorption or solution of soft cata- 
racts by admitting the aqueous humor through needle punctures made 
in the capsule. 4. By removal of soft cataracts through a suction 
syringe or curette after previous needle punctures made some days 
before. 5. By couching or dislocating the lens backward into the 
vitreous. This operation is seldom practised now. 6. By McKeown's 
method, whereby unripe cataracts are operated upon, irrigation being 
used to clear out the residue of the lens. 

Suction and needle operations, generally speaking, are not applicable 
after thirty -five or forty years of age. The use of cocaine renders 
most cataract operations possible without chloroform or ether — a vital 
point, considering the dangers attending the act of vomiting or 
retching. 

Some lamellar cataracts, with a wide, clear, marginal zone, may be 
best treated by doing an iridectomy, which will uncover a transparent 
portion of the lens, and give fairly good vision, 

In young subjects, the best operation is the needle one, and some 
opaque lenses may be completely removed by a few insertions of the 
needle through the cornea and laceration of the anterior capsule and 
fibres of the lens, and exposure of them to the absorptive action of 
the aqueous humor, the posterior capsule being left behind to shut out 
the vitreous. The iris must not be interfered with or touched by the 
needle, and atropine solution (1 : 100) must be freely used before 
and for a time after the operation, or until the next insertion. 

The operation of linear extraction is applicable to soft cataracts 
where the needle fails, and to other cataracts where time is an import- 
ant element, and to some cataracts where needling has already been 
tried. A short incision is made with a triangular keratome a little 
within the margin of the cornea ; iridectomy is unnecessary. The 
capsule is opened by the cystotome or by the point of the keratome. 
By slight pressure on the globe the soft lens substance is evacuated 
piecemeal, any portions remaining behind being soon absorbed, as in 
the needle operation. If instead of pressing out the softened lens a 
fine syringe be inserted, the matter may be sucked out through it. 



CATARACT. 117 

This is known as the suction operation, and, of course, is only applic- 
able to very soft cataracts. 

In the treatment of hard cataracts no operation should be undertaken 
if there be evidence of deep-seated disease. Should there be total 
absence of all perception of light though the cataract be very dense, 
no operation should be recommended, and under no circumstances 
should both eyes be operated upon at the same time. 

There are many modifications and varieties of operation for the 
extraction of hard cataracts. Graefe's modified linear operation is 
performed (1) by making an incision slightly beyond the sclero-corneal 
junction by a long narrow knife ; (2) that part of the iris beneath the 
incision is excised ; (3) the anterior capsule of the lens is freely lace- 
rated ; (4) by gentle pressure the hardened lens is squeezed out of its 
capsule and through the incision ; (5) the " toilette " of the wound is 
to be carefully seen to, and irrigation, by means of McKeown's 
syringe and needles, is far preferable to pressure, either digital or 
instrumental. 

The flap operation is performed by making an incision within the 
visible margin of the cornea for about half its circumference, and 
concentric with it, by entering a Beer's triangular knife at the margin 
of the cornea and cutting out a semi-circular flap without making an 
iridectomy. The capsule is opened by the cystotome, and the lens 
easily escapes through the opening; spontaneously or upon very gentle 
pressure. 

After operation the patient is put to bed in a darkened room, and 
a piece of linen, covered by a pad of absorbent wool, placed over 
each eye and bandanged by a four-tailed knitted cotton bandage. 
This need not be disturbed for forty-eight hours (if all goes well), 
when a few drops of atropine solution (1 : 100) may be instilled and 
the bandage is applied. 

After the fourth day he may be allowed to sit up, and the bandage 
may be removed at the end of ten days and a shade substituted. 

Chisolm operates upon all senile cataracts without iridectomy. He 
cleans the anterior chamber as carefully as possible, and replaces the 
iris so as to establish a round, well-contracted pupil with the lips of 
the corneal wound well adapted. He then instills a few drops of 
eserine solution (half per cent.), and closes the eye with a strip of 
transparent adhesive plaster, after which the patient is permitted to 
walk to his room and recline upon a sofa ; only direct sunlight is 
excluded from the sick chamber. . He eats his regular meals, washes 
himself, sees his friends, walks about unrestrained, dresses and undresses 
himself morning and evening. Atropine is instilled upon the fourth 
or fifth day, when the plaster is removed, and the eye requires no 
further protection. 

McKeown's method of using irrigation marks a very distinct progress 
in ophthalmic surgery. Those who have reported unfavorably of it 
appear not to have grasped the principles upon which the procedure 



118 CATAKKH. 

is founded. In a considerable number of ordinary cataract operations, 
where the cataract is regarded as ripe before operating, the surgeon 
finds that the cortex remains and gives much trouble. Here massage, 
pressure, and the use of the scoop are the usual means by which the 
residual cortex or debris is to be cleared away. 

It is, however, in dealing with unripe cataracts, in those where, 
before operation is attempted, the surgeon knows that he is dealing 
with a transparent and sticky cortex, that the plan of irrigation is 
most valuable. The term irrigation is an unfortunate one ; it would 
be better to speak of it as " the method of removing the cortex by 
fluid pressure." By it the cataract patients, who .were formerly 
doomed to wait for months or years till their sorrow became ripe, can, 
in the majority of cases, be operated upon with every prospect of 
success without delay. This is a great gain in the case of the poor, 
and artesans or laborers. 

The operation is done according to the ordinary methods with or 
without iridectomy, and after the extraction of the lens the fine nozzle 
of an irrigation apparatus (a suspended bottle, with a bent syphon 
tube in the interior, filled with about 4 ounces of warm distilled water 
previously boiled) is introduced through the wound. The strictest 
antiseptic precautions are used. As the stream of sterilized water is 
introduced inside the capsule, "there is.no pressure on the cornea, no 
pushing back of the vitreous, no squeezing toward the wound of the 
hyaloid membrane. The current of water under the control of the 
surgeon flows inside the capsule of the periphery, and returns along 
the anterior and posterior capsule, searching every corner, and bring- 
ing with it fragments of cortex from every part of the capsule. The 
force is equable and gentle, and acts not only on the parts we see, but 
on those concealed by the iris, and quite as well upon the parts con- 
cealed as on the parts visible." The complete extraction of the cata- 
ract, therefore, becomes simply a question of physics, of relative 
resistance, and relative well directed and suitable force. 

CATARRH— See Bronchitis. 

If the local symptoms be distressing at the beginning of an attack, 
and there be much sneezing and coryza, Ferrier's snuff may be insuf- 
flated. The following is the formula for this powder : 

R. — Bismuthi subnit gvj. 

Pulv. acacise gij. 

Morphinse hydrochlor. gr. ij. — M. 

S. — To be used as directed. 

A mixture of iodoform and tannin may be employed in the same 
way. Plugs of cotton wool saturated with cocaine (4 per cent.), or 
menthol (8 per cent.), may be inserted into the nostrils. Solution of 
nitrate of silver, 10 grains to 1 ounce, may be freely applied with a 



CHAPPED HANDS— CHILBLAINS. 119 

brush, or zinc sulphate, five grains to 1 ounce, may be tried. Sprays 
of weak carbolic solution (1 : 80), ipecac wine or sulphurous acid, 
inhalations of ammonia, ammonium chloride, carbolic acid, benzoin 
(tinct. benzoin, comp.), camphor, weak iodine solutions (30 minims of 
tincture to 1 ounce of water) eucalyptus, and many other remedies men- 
tioned under Bronchitis, may be used. In the chronic form of nasal* 
catarrh, the chloride of ammonium inhaler is the best. 

Benzoate of soda in drachm doses may be given at the beginning of 
an attack, and often one full dose of morphine cuts short the coryza 
before the irritation extends downward. Belladonna or atropine 
(1 minim of the 1 : 100 solution), often affords relief if given every 
six hours. (See also under Hay Fever.) 

CEREBROSPINAL FEVER— See Meningitis, Cerebro-spinal. 

CHANCRE— See under Syphilis. 

CHAPPED HANDS. 

The skin should be protected as much as possible from atmospheric 
changes, and when washed or wetted should be carefully rubbed dry 
with warm towels. The practice of partially drying with damp clothes, 
and then heating before a fire, has much to answer for in causing the 
affection. A superfatted soap (vinolia) is the best, and of all the 
numerous applications there is none to equal the following ointment, 
which frequently works wonders in one night : 

R . — Liq. carb. deterg g jss. 

Hydrarg. amnion. . gr. xxv. 

Lanolini ^ij. — M. 

This applied freely at night with gentle friction, and covered with 
chamois gloves, very often removes the condition after a few days. 
Other good applications are glycerin, glycerin and rose water (1 : 5), 
glycerin and Friar's balsam (4 : 1), glycerin and eau de cologne 
(2 : 1) glycerin of starch, glycerin and diluted lead solution (1 : 8), 
glycerin and hydrastis (glycerin, 3; tinct. hydrastis, 1 ; rose water, 10), 
vaseline, and cold cream. 

CHILBLAINS. 

In the early or erythematous stages, the proper treatment is to bring 
the circulation of the part to its normal condition by friction with a 
stimulating liniment. Thus, when first noticed, if the chilblain is per- 
severingly rubbed with the following application, it soon disappears : 

R. — Spt. camphorse . . . . . . ^ij. 

Tinct. capsici . . gj. 

Tinct. cannab. ind gj. 

Olei cajuputi gj. — M. 



120 CHILBLAINS. 

Lin. camph. comp. is a good application, as is also the following: 

R. — Lin. saponis ........ ^iij. 

Chloriformi . . . . . . . • 3J- 

Lin. belladonnse giv. — M. 

With some patients, one good application of liniment of iodine with 
a brush is followed with satisfactory results. Arnica should never be 
used, and aconite gives relief, but leaves matters worse ultimately. It 
relieves the itchiug. Belladonna liniment painted on also affords re- 
lief, and does not interfere with the local nerve supply. Equal parts 
of turpentine and olive oil, with i part of chloroform,* is a good ap- 
plication. Oil of eucalyptus may be also rubbed in before the skin 
breaks, and a little thymol or menthol may be added. 

If blebs form, they should be snipped, and the part dressed with the 
following ointment : 

R. — Ung. zinci oxidi . . . . . . gj. 

Tinct. benzoini comp, . . . . . gij. 

Lanolini giv. — M. 

Precipitated carbonate of zinc ointment, 8 parts, balsam of Peru, 
1 part, is a very good ointment. Plain basilicon ointment is perhaps the 
best of all applications at this stage if applied spread upon lint. Flexile 
collodion may be used where dressings cannot be worn, and it is best 
if applied before the skin breaks. A 20 per cent, ichthyol-lanoline 
ointment makes a very valuable dressing to the sores. 

Should the ulcer be tedious in healing, it may be treated as an or- 
dinary sore, and a weak solution of chloral hydrate (5 grains to 1 
ounce) is the best application, or any of the numerous methods and 
drugs mentioned under Ulcer may be resorted to. 

Besnier treats chilblains by bathing the hands in a decoction of 
walnut leaves, drying and rubbing in spirit of camphor, and dusting 
over with a powder consisting of salicylate of bismuth, 1 part ; starch, 
9 parts. 

Vigorous exercise in the open air, even in coldest weather, avoid- 
ance of heating the hands and feet before the fire, a generous diet, 
warm flannels, and no hot water bottles should be allowed in bed. The 
lowing is a good remedy for internal use 



R . — Tinct. ferri chlor. . 
Quininee sulph. 
Tinct. digitalis 
Glycerini 

Aquse .... 
S. — Take a teaspoonful in a wineglassful of w 



. siv. 

• S3- 

■ 3ij- 

• • §ij- 

. ad £vj.— M. 

ater, four times a day, after meals. 



Ichthyol internally has been recommended, but the writer has never 
tried it. He has observed excellent results from nine Blaud's pills in 
the day. 



CHLOASMA — CHLOKOSIS. 121 

CHLOASMA. 

Confining the term to the affection characterized by the presence of 
pigmented spots (ephelides or freckles) or patches, caused by the 
deposition of pigment in the cells of the rete mucosurn, the treatment 
will be to destroy the epidermis in which they are situated. Hebra's 
method is to apply a lint compress for four hours, soaked in solution 
of bichloride of mercury (1 : 100), letting out the blister formed, 
and dressing the resulting raw surface with powdered starch ; or 8 
grains of the mercurial salt may be dissolved in 8 ounces of almond 
emulsion, and sponged over the spot several times daily. Unna ap- 
plies a plaster made with hydrarg. ammon. for twelve hours, and 
dresses afterward with an ointment of bismuth (1 drachm to 1 ounce). 
Tincture of iodine, carbolic acid, sulphurous acid, peroxide of hydro- 
gen, acetic acid, and many other mild counter-irritants are also suc- 
cessful. 

Crocker uses an ointment of 10 to 20 grains of veratrine to 1 ounce 
of lard. 

Cantharides should never be employed ; it increases pigmentation ; 
so does mustard. Wilson uses potash soap and alkaline lotions. 
Chrysarobin is efficacious, but owing to its staining properties, it 
should never be used when other agents do so well. The large 
patches of chloasma on the foreheads of pregnant women, or in those 
suffering from uterine or ovarian irritation, disappear when the cause 
is removed. 

CHLORAL POISONING— See under Poisoning by Chloral. 

CHLOROFORM NARCOSIS AND CHLOROFORM POISONING 

will be found referred to under the heading of Poisoning by Chloroform 
(where also will be seen the report of the Hyderabad Commission.) 

CHLOROSIS. 

The treatment of this condition has been referred to in discussing 
the management of anaemia and amenorrhcea, and it may be summed 
up in the word " iron." Blaud's pills, 2, four times daily ; 30 to 60 
minims of dialysed iron ; or 15 minims of the ordinary tincture, well 
diluted, are the best preparations. The dose of the metal, in whatever 
preparation selected, should be large and often repeated. 

The constitutional treatment is also mentioned under the above- 
named conditions. It may now and then, in rare cases, be found that 
the results of iron soon cease after stopping its administration, and it 
will be well to leave off for a period, in which arsenic may be given, 
or the iron and arsenic may be given together. 

Albuminate of iron has been much praised, and enemata of de- 
fibrinated blood of oxen has given excellent results lately. (See 
Anaemia and Amenorrhoea.) 

9 



122 CHOLERA ASIATICA. 

Sir Andrew Clarke insists upon the necessity of giving purgatives, 
and gives one-sixth part of the following twice a day : Ferri sulph., 24 
grains ; Magnes. sulph., 6 drachms ; acid, sulph. arom., 1 drachm ; 
tinct. zingib., 2 drachms; inf. gent, comp., ad 8 ounces. 

When this acid mixture produces sickness, and dries the skin, and 
is badly borne, he prescribes the following : 

R 



-Ferri sulphatis 


. gr. xxiv. 


Sodii bicarb 


. . 3ij. 


Sodii sulphatis 


• 3vj. 


Tinct. zingiberis 


Sij 


Spt. chloroformi 


• • • • & 


Infus. quassiae .... 


ad ^viij. — M. 



S. — One-sixth part twice daily, about eleven and six o'clock. 

CHOLERA ASIATICA. 

The writer has had no experience whatever of this affection, and 
there is much difference of opinion, among those who have seen it, 
regarding the best treatment to be adopted. Only those general prin- 
ciples which have been most generally accepted need be detailed. 

Opium, to stop purging, should be freely given, and it would seem 
obvious that it should be given in solution. It may be administered 
during the period of premonitory diarrhoea, and during the period of 
diarrhoea in the fully established malady, but should be withheld when 
collapse sets in ; 15 to 20 minims of laudanum, with 3 grains of acetate 
of lead, may be given after each loose motion for four times, or dilute 
sulphuric acid may be freely given. A large mustard poultice should 
be applied over the surface of the abdomen. Hypodermics of mor- 
phine and atropine may be given to check the diarrhoea where vomit- 
ing occurs. Dr. Harkin has obtained good results by applying a 
blister over the course of the vagus in the neck. Ice in unlimited 
quantities may be given, and all liquids prohibited. If the diarrhoea 
continue, the opium may be cautiously pushed. It is, however, better 
to give the acetate of lead alone, dissolved in distilled water, to which 
a little vinegar is added ; 2 grains may be given every hour, and the 
opium every two, threej or four hours as necessary. Should these 
efforts fail, 20 grains of calomel may be administered. 

If collapse has set in, stimulants must be given in desperate cases 
freely. Friction and hot-water bottles to the surface of the body, and 
hypodermic injections of ammonia and camphor, and enemata of 
brandy and beef tea are used, if the bowels are quiet. Iced water 
may be freely given, and champagne often saves the patient until the 
reaction period sets in, after which all treatment should be eased off, 
and iced milk or arrowroot and enemata of beef tea given every four 
hours. Vomiting may be combated with creasote or carbolic acid (1 
minim), copper sulphate (1 grain), or turpentine. 

Saline injections into the veins, or milk may be similarly employed 



CHOREA. 123 

or injected into the peritoneal cavity in formidable collapse, and a hot 
bath may be administered in the cold stage. Oxygen inhalations have 
been credited with saving life. 

Almost every new antiseptic is vaunted, until numerous trials prove 
it to be no better than the old agents. Salol is at present enjoying 
some reputation upon the strength of Lowenthal's statements and ex- 
periments. 

The following is a good astringent formula which may be used to 
relieve the diarrhoea prevailing about the period of cholera epidemics : 

R .— Tinct. kino .... 
Tinct. catechu comp. 
Tinct. opii 
Spt. setheris .... 

Mist, cretse ad ^vj. — M. 

S. — Take one tablespoonful after each liquid stool, the bottle having been first 
shaken. 

CHOLERA INFANTUM- See Diarrhoea. 

CHORDBE— See Gonorrhoea. 

CHOREA. 

Of the host of remedies recommended from time to time for the 
treatment of chorea, only three or four are of real value. A disease 
so liable to get well in many cases if left to itself is certain to have 
scores of specifics, and whatever drug the observer had chanced to 
give, he is liable to attribute the spontaneous cure to its influence. 
While many case of chorea will recover if left alone without any 
medicine whatever, it is equally certain that many will go on from 
bad to worse if not arrested. It is also certain that we have drugs 
which, if judiciously administered, possess the power of arresting the 
disease. 

Rest in bed, suitable clothing, ventilation, cold sponging, good food, 
and abundance of it carefully administered, will go a great way to 
effect recovery. Rest in bed and freedom from all excitement is 
essential in all bad cases. 

Often the condition is associated with anaemia, and when this is 
remedied the chorea passes off. It will be wise, when a mild case 
comes before the physician for the first time, at the very commence- 
ment of the symptoms to attend to rest and feeding, and abstain from 
very active drugging. A small quantity of tincture of iron, with cod- 
liver oil or malt extract, cannot fail to improve the general health 
when associated with a few mild doses of a saline purgative. If the 
movements, however, have lasted for any time — a week or more — the 
patient should at once be placed upon a course of arsenic. From a 
very extensive experience of chorea in a children's hospital, the 



124 CHOREA. 

writer has thoroughly satisfied himself about the great value of the 
drug iu this affection, and he is led to state that the cases of reported 
failure are generally owing to a mistake in the dosage. 

Choreic children bear larger doses of arsenic than would at first 
sight seem possible. These large doses are also necessary to produce 
an effect upon the disease. Given in the ordinary doses, say of 1 
minim of Fowler's solution for a child two or three years old, or of 2 
or 3 minims for a child of six or seven, arsenic probably produces 
little or no benefit, and the writer has seen several cases where the 
drug was said to have failed, which have rapidly improved when the 
proper dose was administered. Something very like this, is seen in 
the treatment of ansemia and chlorosis with small doses of iron. It is 
a well-established fact that these affections may be for a long time 
treated by ordinary doses of some iron preparation without any appre- 
ciable benefit, but almost immediately improvement is noticed after 
the administration of large doses— doses much larger than can possi- 
bly be assimilated. Thus Seguin gives up to 25 or 27 drops after 
each meal in a large tumblerful of alkaline water in divided drinks 
during the hour following the meals. 

For a child of seven years old with choreic movements, Fowler's 
solution may be commenced in doses of 3 minims three times a day, 
and the dose may in a week be brought up to 10 minims three times 
daily without producing any untoward symptoms, and this dose can 
be taken for many weeks. Should improvement be very slow, the 
arsenic may be pushed until griping and indigestion or signs of irrita- 
tion of the conjunctiva, or nasal mucous membrane show themselves. 
Iron may be combined with it, but not in doses proportionately large, 
and it should always be given after a full meal. The following is a 
good working formula : 

&. — Tinct. ferri chlor 2>ij- 

Liq. arsenicalis (Fowler) giij. 

Glycerin! §j. 

Aquae clestillatse ad ^ v. — M. 

S.- — Take a teaspoonful, by measure, in water, three times a day, after meals. 

In the great majority of cases no farther treatment will be required. 
Next to arsenic comes sulphate of zinc. It is not safe to give out 
bottles containing large quantities of arsenic amongst the promiscuous 
crowds of the extern department of a children's hospital, and here it 
is well to have a remedy at hand which, if swallowed by mistake in 
large quantities, will not cause fatal, results. Beginning with 2 or 3 
grains, soon increased to 8 grains, the effects of sulphate of zinc are 
well marked, and it is rather surprising to see how soon the stomach 
becomes accustomed to large doses without producing nausea. It 
should be given in solution immediately after a meal, and four times a 
day. The sulphate of copper and nitrate and oxide of silver appear 



CHOREA. 125 

to act in the same way, but they have no advantages over zinc salts, 
and are even more dangerous than the arsenic if swallowed in large 
quantities by mistake. Other remedies used occasionally with benefit 
are apomorphine, lobelia, and tartarated antimony, given in doses to 
produce nausea bordering upon vomiting. 

Bromides of potassium, ammonium, sodium, and zinc in full doses 
to allay nerve excitement have proved useful, and Goubert gives the 
bromide of gold in doses of y 1 ^- grain until sleep comes on. 

Aetata racemosa, iodides, and salicylates, in cases where the attack 
has a more than ordinary association with acute rheumatism. The 
first-named remedy has been much praised, the writer believes without 
possessing any decided merits. 

Phosphide of zinc (^ grain for a child seven years old) and the 
valerianate of zinc (in f grain doses) act somewhat like the sulphate, 
but less satisfactorily. The oxide may be given in doses as large as 
the sulphate. 

Strychnine was recommended highly by Trousseau, who gave it in 
gradually increasing doses until mild symptoms of poisoning began to 
show themselves. It is stated to be still the best remedy for chorea 
caused by a fright, but it is the writer's experience to find that a his- 
tory of fright is to be found in very many cases of the disease. 

In the very severe cases of acute chorea, threatening seriously to 
cut short the little patient's career from the exhaustion caused by the 
ceaseless movements of the limbs and body, a different set of remedies 
must be employed. Here, to wait for the action of zinc, arsenic, or 
iron is out of the question. It is in these comparatively rare cases 
that the remedy recommended by Harley is indicated. He gives 
conium juice in large doses until the physiological effects are observed. 
Einger gave " to a child " 7 drachms of the juice every hour, unless 
when asleep. Unfortunately, the effect of the drug is not lasting, but 
the writer was able in one bad case to keep the child alive until arsenic 
had time to act. 

Chloral is of the greatest use in these cases in gradually increasing 
doses. A child seven years old might be cautiously started upon 3 
grain doses. 

Gairdner mentions an interesting case in a girl aged eight, who was 
taking 15 grains three times daily. She then got 60 grains by mis- 
take, and though her life was in great danger, she recovered, and the 
chorea was cured. He states that it has an almost absolute power of 
suspending or controlling spasm during the persistence of its deep 
hypnotic action. 

Bastian has treated several cases by keeping the patient asleep for 
several weeks, except for half-hour intervals, during which she was 
fed. This appears to the writer to be a very questionable method of 
proceeding with a dangerous drug. 

Chloralamide may be pushed with greater safety, and excellent 
results have followed its use. 



126 CHOEEA. 

Belladonna and hyoscyamus may be tried, and in a few cases can- 
nabis indica has given rest ; more frequently it is useless, or aggravates 
the symptoms all round. 

In desperate cases the vapor of chloroform may be inhaled, and if 
sleep supervene without the cessation of movements, it may be continued 
at short intervals cautiously. Ether may be given. Antimony has 
occasionally given rest in these acute cases, but it interferes seriously 
w T ith appetite and digestion, and it is of vital importance to sustain life 
by stimulants and good feeliug. 

Curara has been employed in doses of -^ grain for a child hypo- 
dermically, and though it is doubtless a remedy of some value, its 
effects are very evanescent, and they cannot with safety be kept up for 
any length of time. 

Physostigma in powder, extract, or alkaloid has been tried, and is 
open to the same objections as the previous remedy, so that upon the 
whole it is doubtful if its administration is justifiable ; ^ grain of 
physostigmine for a child seven years old may be given hypodermically 
every four hours, and Reiss claims that he cures chorea with eserine 
hypodermically in five or six days. His dose is y 1 ^- grain twice daily. 

Ether spray applied along the spine is not open to any objection, and 
sometimes produces refreshing rest in severe cases, and should always 
be tried. It is better than cold douches and the spinal ice-bag. Methyl 
chloride spray has been also used. 

Morphine hypodermically may be given to induce sleep, but the 
greatest caution should be exercised in treating children in this way, 
and the writer would be slow to ever try it. 

Sulphonal is perfectly safe, and may be given in full doses. More- 
over, it has been given as a routine remedy for the disease with some 
show of success, even where sleeplessness was not a feature. As just 
mentioned, chloral or chloralamide may be resorted to when insomnia 
is present. 

Cypripedium, the eclectic preparation from "ladies' slipper," has 
been given in doses of 1 grain every two hours to young children. Its 
reputation rests upon very slender evidence. 

Antipyrine and antifebrin have been recently tried, both in the mild 
and grave forms of chorea, occasionally with marked success, and their 
effects may safely be tried where the better known remedies fail. With 
our present knowledge of their pharmacology and of the pathology of 
chorea we do not know beforehand the class of cases in which they will 
succeed. Antipyrine may be given in 2 grain doses every three hours 
to very young children. 

Static electricity has been used, but its value has yet to be estab- 
lished. General galvanism has occasionally given good results, but the 
strong, interrupted currents recommended by some writers are not to 
be sanctioned. 

Restraint of the excessive movements, when judiciously carried out 
by a skilful nurse, and proper bandaging of the upper limbs to the 



OHYLURIA — CHOROIDITIS. 127 

trunk, and the lower extremity to each other, often gives some relief 
in the grave affection. Should it increase the patient's discomfort, it 
should not be persisted in. 

Heart complications may require attention, but unless these be of old 
standing, it is not good practice to begin pouring in full doses of digi- 
talis and strophanthus. 

Cod-liver oil is useful at all stages of the disease, and during conva- 
lescence, when the movements have ceased, moderate exercise and lim- 
ited gymnastics may be indulged in. 

OHYLURIA 

has yet to be satisfactorily treated. No remedy appears to possess any 
constant effect upon the appearance of suspended fatty matter in the 
urine, generally caused by the presence of filarial in the blood and 
lymphatic vessels. 

Benefit is obtained for a short time by decoctions of the bark of rhi- 
zophora racemosa (the mangrove), or preparations of the seed of nigella 
sativa. Stephen Mackenzie got promising results from benzoate of 
soda in drachm doses three times a day, but was unable to follow out 
the after- history of the cases. Gallic acid (in 1 to 2 drachm doses) 
always affords some benefits, and large doses of tinct. ferri chlor. do 
some good. Antiseptics have failed, but large doses of iodide of potas- 
sium appear to have checked the discharge for a time in several cases. 

CHOROIDITIS, 

if of syphilitic origin, will yield to active mercurial treatment, and if 
got at an early stage, mercurial inunctions are especially indicated, 
and should be continued for a considerable period. In acute cases 
occurring late in syphilis, large doses of iodide of potassium may be 
tried first. In acute or subacute cases, where sight has recently been 
failing from areolar or diffused choroiditis, where no history of syphilis 
is obtained, and where the kidneys are sound, the hope lies in small 
doses of the bichloride of mercury (y 1 ^ grain four times a day), com- 
menced after a brisk saline purgative. Bloodletting by leeching of 
the temples, followed by the application of a small cupping glass, or 
preferably by the use of Heurteloup's leech, should be at once resorted 
to, and any deviation from the standard of health attended to. Abso- 
lute rest to the eyes must be insisted upon. Pilocarpine hypoder- 
mically, in doses of -j- to i grain, is the best remedy where recently- 
effused products have to be dealt with. Where detachment of the 
retina, or of the retina and choroid together, has taken place, a small 
valvular puncture should be made in the sclerotic to provide for the 
evacuation of the sub-choroidal fluid and the replacement of the de- 
tached membrane. This treatment should be followed up by blistering 
or smart c mnter-irritation over the temples and behind the ears. 
For the chronic disseminated choroiditis, chiefly observed in chil- 



128 CLEFT PALATE. 

dren, the offspring of syphilitic parents, little or nothing can be done, 
unless there chance to be some recent or active inflammation going 
on. Generally the defect in vision is only noticed long after the active 
stage is passed, and when the period has expired during which treat- 
ment would be of any use. The necessity of treating every departure 
from the normal standard of health in such subjects need hardly be 
referred to. 

CLEFT PALATE 

can, of course, only be satisfactorily dealt with by an operation. As a 
rule, this should not be undertaken, in cases where the soft palate is 
alone involved, till the patient is past the period of the first dentition. 
About two and a half years of age is a good time. Where the hard 
palate is involved in the cleft, about double this age is the best period 
for operative interference. 

The uvula being caught firmly with forceps, the margins of the cleft 
in the soft palate are carefully pared. Sutures being passed, the mar- 
gins should be approximated. If there be much tension, an incision 
should be made a short distance outside the cleft on each side, and 
parallel with it, to allow of accurate adjustment of the pared edges 
without undue tightness of the sutures. Where the fissure extends to 
the hard palate, an attempt can at the same time be made to close it 
also. 

The periosteum being dissected from the bone on each side of the 
margin of the cleft through incisions parallel to the cleft, and a little 
distance outside it, the edges of the muco-periosteum are sutured and 
brought into position, as in the case of the soft palate. If the gap be 
wide and tissue very valuable, the edges need not be pared, but simply 
everted ; as the sutures are tied, the eversion secures the approxima- 
tion of the raw upper surface of the flap. The most careful feeding 
and nursing are required. The sutures may be removed about the 
eighteenth day. 

In cases where the condition has been neglected, and the patient 
first presents himself for the treatment of a cleft in the hard palate in 
adult life, the operation of Sir William Fergusson may be decided 
upon. But the writer would say, after witnessing Sir William perform 
the operation himself in 1874, that it should not be entered upon with- 
out serious consideration. The perforation, and subsequent chiselling 
and detachment of the segments of bone being a most protracted and 
bloody operation, and not always followed by success, and if success be 
achieved, one may well question " if the game be worth the candle." 

Such a case may be made comfortable for the remainder of the 
patient's life by having a gold or thin vulcanite plate accurately adapted 
to the roof of the mouth, covering the fissure, and having an artificial 
tympanum or soft palate of India-rubber attached behind. The plate 
may carry any artificial teeth to fill gaps in the row of incisors, and it 
may be attached to the sound molars. 



CLUB-FOOT. 129 

CLUB-FOOT. 

The treatment of the different varieties of this affection is carried out 
by various surgical procedures, whose object is to overcome the con- 
tractions or shortenings in the muscles upon one aspect of the limb, 
while upon the elongated side of the affected leg or foot attempts should 
be made to increase the strength and tone of the muscles and other 
structures. Tenotomy will only be required in the severer forms of 
the deformity. If the foot can be easily brought into its natural 
position by flexion or extension without the use of any force, perma- 
nent removal of the deformity may be achieved by careful and frequent 
extension of the contracted tendons and massage of the weakened mus- 
cles upon the opposite aspect of the limb, carried out several times a 
day by a skilful nurse. 

'Where some force is requisite to get the foot into the normal ana- 
tomical position, and keep it there, it will be necessary to secure it in 
this position by strapping, so applied as to counteract the tension exer- 
cised by the shortened tendon. If the necessary force be greater than 
strapping will afford, a simple splint, with a moderetely firm bandage, 
may accomplish this. 

Many paralytic cases of club-foot will yield to these measures, and 
the writer has had very satisfactory results by injecting small doses of 
strychnine into the weakened muscles in cases following poliomyelitis 
anterior acuta. Galvanism, a weak, interrupted current or a strong, 
continuous one, will sometimes restore power to muscles when they 
have apparently disappeared altogether, but the remedy must be per- 
sisted in for a long time. 

In congenital cases the extension and massage should be commenced 
as soon as the affection is recognized. If these measures fail to pro- 
duce decided improvement, or if the strong force required to bring the 
foot into its position, convinces the surgeon that these measures are 
inapplicable from the first, the contracted tendons should be divided 
with a tenotomy knife subcutaneously, and the foot in its deformed 
position should be bandaged to a splint for a few days to keep the 
divided ends of the tendon from separating. Gradual extension by 
means of a Scarpa's shoe may be commenced after some uniting mate- 
rial has been poured out between the cut ends of the tendon. 

The different varieties of talipes will, of course, require division of 
different tendons when they fail to respond to simililar treatment, and 
the different examples of each variety may demand different operations, 
thus for equinus the tendo Achillis may only require division, whilst 
in another case the plantar fascia must be incised also. 

The congenital equino-varus presents considerable difficulty in its 
treatment. It is best to remedy the varus, and afterward divide the 
tendo Achillis. The first object is achieved by tenotomy of the tibialis 
anticus, tibialis posticus, and flexor longus digitorum. After treat- 
ment by extension for five or six weeks, the plantar fascia and tendo 
Achillis are divided, and a suitable boot and appliance made by 



130 COCCYDYNIA. 

an instrument-maker, adjusted to the limb, by means of which stretch- 
ing of the contracted tendons may be kept up for many weeks, mas- 
sage and passive movements being continued daily for months after- 
ward. The other varieties of tallipes are treated upon the same gen- 
eral principles, always remembering that after tenotomy operations 
the mechanical stretching of the divided tendons must be kept for up 
a long time. 

Ogston, relying upon the cause of club-foot being an arrest of the 
foetal unwinding of the limb, which affects all the structures of the 
foot and leg, denounces as most unscientific the division of a tendon in 
its sheath "for no union between its divided ends is possible, and any- 
thing more useless in treating ordinary club-foot could scarcely be 
named. Promiscuous tenotomy is both unscientific and unnecessary." 
He approves of Hiiter's method of keeping the limb in a rectified 
position (after manipulation by the hand under chloroform) by means 
of a fixed bandage of Cafferatas best plaster-of-Paris (as being better, 
because requiring less skill and patience than splints), elastic traction, 
and other apparatus. 

The plaster splint is applied at about the age of six weeks, by means 
of book-muslin plaster bandages, applied direct to the skin, the limb 
being held in as near the normal position by plaster-loops until the 
bandage is applied, after which it is held until the plaster sets. He 
permits these to remain on for six weeks. The varus position should 
always be corrected before touching the equinus. For this he always 
divides the tendo Achillis, and applies the bandage from the foot to 
half-way up the thigh, with the knee extended. In older cases the 
choice lies between cuneiform exsection of the tarsus, linear oste >toiny 
of the tarsus, or Lund's excision of the astragalus or osteotomy of the 
tibia or fibula. 

OOCOYDYNIA. 

Sir James Simpson's operation of subcutaneous section of the coccy- 
geal muscles is the only remedy for this most obstinate affection. Where 
this operation fails, Notts' practice of excising the coccyx will also 
generally be found to fail. Some relief may be obtained by wearing 
a belladonna plaster, cut to the shape of the parts, and terminating in 
a pointed end or tail, which covers the skin over the lower part of the 
sacrum and coccyx, coming forward to near the anus. Any local 
anaesthetic may be employed from time to time to give temporary 
relief, and occasionally benefit is derived from the application of a 
blister or counter-irritant, like the liniment of iodide, or Corrigan's 
iron. 

The continuous current and the hypodermic injection of antipyrine 
may be tried. Any uterine or ovarian source of irritation should be 
closely looked out for, and codeine may be indicated as having, though 
less power to relieve than morphine, less danger of establishing the 
terrible opium habit. 



131 



Meniere uses the following suppos 

& . — Ext. belladonna; 
Ext. hyoscyami 



Or, 



Iodoformi 

Olei tlieobromatis . 

K. — Choral hydrat. 
Ext. Valerianae 
Olei tlieobromatis . 



COLIC, Biliary— See Gall-stones 



tory at bedtime 



gr. 
gr. 
gr. 
gr. 

gr. 
gr. 

gr. 



4- 
XX. 



JSS. 



-M. 



-M. 



COLIC, Intestinal. 

The cause of the attack will often afford the best indication for the 
nature of the treatment required. Thus the colic of infancy generally 
depends upon an error in feeding, and in the majority of cases will be 
found to depend upon the presence of indigestible milk curd, which, 
if not speedily remedied, may give rise to rapidly fatal enteritis. A 
smart purge (1 or 2 drachms of castor oil), combined with carminatives 
and a change of diet, will give permanent relief. If the milk of the 
mother or a healthy wet nurse is not available, Nestle's food is de- 
cidedly the saftest and nearest port in the storm in cases of severe, 
intractable colic in infants. 

The minor attacks of infantile colic should never be treated by 
laudanum. The oil of anise, 2 to 3 drops on sugar, may be given 
every hour. Peppermint is more suitable for children and adults. 
Dill water, with a little magnesia, is a favorite domestic remedy. 



R. — Magnes. carb. 
Syr. zingib. 
Spt. chlorof. . 
Aqua; anisi 
S. — Take a teaspoonful every hour 



. gr. xx. 
ad ^ij. — M. 



if needed. 



In adults, if the colic depends upon the presence of any irritating 
or indigestible or fermenting food, a smart purge, with opium com- 
bined, should be given. Castor oil is the safest of all cathartics in 
such cases, as there is always the remote possibility of some abdominal 
mischief lying behind the attack. 

The following is a well-tried formula : 

Be. — 01. ricini gvj. 

Tinct. rhei aromat. ^ij. 

Tinct. opii . Tltxx. 

Aqua? cinnamomi ad ^ij. — M. 

S. — To be taken immediately, the bottle having first been shaken. 



132 

6 grains of calomel, with J grain of morphine, may be placed upon 
the tongue if vomiting is present, or I grain of morphine may be given 
in suppository, after a large warm-water enema. Before the cathartic 
acts, the patient may be put in a hot bath (at 104°), and a large lin- 
seed and mustard poultice applied to the abdomen after he is put to 
bed. Hot turpentine stupes may be used instead of the bath. The 
ordinary India-rubber bottle, filled with hot water, and laid against 
the stomach region, affords great comfort in all cases. 

Should the pain continue unrelieved, a hypodermic of ^ grain of 
morphine, with 1 minim of the 1 : 100 solution of atropine, may be 
given in conjunction with a glassful of hot punch. "Chloroform has 
been administered where the suffering has been acute, but in simple 
colic it must be seldom required. The following may be tried in 
chronic cases, or where the attacks recur : 

Asafgetida — The tincture or fetid spirit in doses of 1 drachm. 

Sal Volatile — In teaspoonful doses, largely diluted or combined 
with whiskey or brandy. 

Ether — In teaspoonful doses of the spirit, or of Hoffman's anodyne, 
or even teaspoonful doses of the pure ether might be given alone, or 
in a little spirit. 

Belladonna — 20 minims of the tincture may be administered at 
one dose. 

Ginger or Cardamoms — In teaspoonfuls of the tinctures diluted. 

Essential Oils — Cajuput (5 minims), chamomile (3 minims), 
peppermint (5 minims), cinnamon, cloves, or caraway (3 minims), 
or camphor, 5 grains, every two or three hours. 

Nux Vomica is much praised ; the writer never saw it give relief. 

Cocculus Indicus, from which picrotoxin is obtained,' is said by 
Brunton to relieve colic in pregnancy. Each of the above will do 
likewise without any of the dangers attending the use of this drug. 

Chlorodyne — 15 to 30 minims is a popular remedy of great power 
and certainty of action. 

COLIC, Lead. 

A smart purgative should be given at once when the patient first 
comes under observation. 1 ounce of sulphate of magnesia is the most 
suitable. Castor oil acts satisfactorily, but the sulphate can be re- 
peated every three hours in teaspoonful doses if the first dose fails to 
act, whilst repeated doses of oil cannot be tolerated. Should the pain 
be severe, any of the remedies mentioned upon the previous page may 
be administered with the view of giving temporary relief. After the 
evacuation of the bowels, the patient should be put upon a course of 
iodide of potassium to cause elimination of lead from the system. This 
course may be well supplemented by a morning purge caused by the 
sulphate of magnesia. 

Diluted sulphuric acid, in 20 minim doses, may be taken in half a 



COLLAPSE (AND SHOCK). 133 

tumblerful of water as a drink frequently during the day, or lemon- 
ade made with sulphuric acid instead of citric and tartaric acids, as 
ordinarily employed by lemonade makers. This beverage is a valu- 
able prophylactic, and may be given with the iodide in bad cases. 

Alum, in full doses, sometimes purges in the obstinate constipation 
of lead colic, and it is also said to relieve the pain when purging does 
not occur. It may be given in doses of 20 grains. 

Sulphur, onions, garlic, eggs, Harrogate water, and other sulphur- 
containing bodies have been used successfully with a view of causing 
elimination. Sulphur baths have been recommended for the same 
reasons, and a diet of milk in large quantities favors convalescence. 
(See also under Plumbism.) 

COLIC, Renal— See Stone in the Kidney. 

COLLAPSE (and Shock). 

The most obvious indication in the majority of cases of collapse, 
from whatever cause, is to attend to the condition of the heart. The 
horizontal position must be enforced, and the falling body-heat cor- 
rected promptly by warmth to the surface at every point with hot 
blankets, water bottles, and gentle friction. The cutaneous circula- 
tion, and, reflexly, the circulation in other parts, should be stimulated 
by mustard to the spine, nape of the neck, and calves of the legs. 
Brandy or whiskey punch should be given if the patient can swallow; 
if not, these remedies must be administered by the bowel or by hypo- 
dermic injection, though this latter method is very objectionable, 
owing to the bulk of the necessary amount of alcohol. Should the 
hypodermic method be the only available route in desperate cases, 
then ammonia (weak solution or sal volatile) should be injected 
under the skin or into a vein. Ether may be substituted with 
advantage. 

Digitalis, strychnine, strophanthus, belladonna, and cardiac stimu- 
lants of this class are employed, but their action is too slow to be re- 
lied upon in emergencies. Ammonia to the nostrils is a much better 
remedy. Electricity may be applied to the phrenic nerve, or an in- 
terrupted current may be sent through the upper extremities. Lie- 
big's extract in large doses with hot water, is a rapidly acting stimu- 
lant. 

Should the collapse or shock be associated with extensive hemor- 
rhage, subcutaneous injections of warm saline solution, or transfusion, 
may be performed (see page 37) ; or a temporary ligature or tight 
bandage may be applied to the thighs to prevent the blood entering 
the lower extremities ; or, what is much better, an Esmarch's elastic 
bandage to the limbs, or a tourniquet applied to the femoral artery 
may be tried. 

If a serious operation must be performed, unless there be hemor- 



134 COMA — CONCUSSION. 

rhage going on, the surgeon should wait until reaction symptoms are 
positively established, but he should not wait too long. If he operate 
during the stage of acute collapse, death will probably ensue, while, 
if the operation be performed after the establishment of complete 
reaction, the shock of the operation may cause a fatal second collapse. 
(See Syncope and Concussion.) 

COMA. 

Treatment is useless unless the physician can form some idea of the 
cause of the coma or deep stupor. Thus a head injury, meningeal 
inflammation, apoplexy, sunstroke, opium or alcohol * poisoning, urse- 
mia, or hyperpyrexia may be the cause, and should be promptly met 
by the treatment as detailed under the heading of the individual pri- 
mary affection. 

Thus the large dose of calomel given to an apoplectic patient, may 
cause the death of a patient seized with coma from diseased kidney 
if administered to him. To treat the coma of opium as one would 
treat the profound unconsciousness caused by hyperpyrexia, would be 
to allow the patient to speedily pass' beyond the reach of remedies. 

Where no evidence whatever can be obtained of the cause of the 
coma, say, in a subject picked up in the streets, sinapisms may be 
applied to the back of the neck, spine, abdomen, or back of the legs. 
If there be even a suspicion of poisoning, the soft tube of the stomach 
pump should be passed, and the contents drawn off and examined. 
No harm can come from such procedure, while, should the patient die 
without this having been done, and subsequent information be forth- 
coming at the coroner's court, serious blame will be meted out to the 
attendant, even though pumping would have been useless. The writer 
has often got valuable information by using the catheter in such cases 
and examining the urine drawn off. 

A smart purgative — one drop of croton oil — is the safest and can 
do no harm ; often the cold douche may be used. (See the treatment 
of each of the primary affections under its OAvn heading, i. e., Apoplexy, 
Uraemia, Poisoning by Opium, Alcohol, etc.) 

CONCUSSION. 

The treatment of the condition spoken of as concussion of the brain, 
may be best managed by carrying out the suggestions made under the 
head of Collapse. The violent shaking, causing the shock to the 
patient's nervous system, is best met by absolute rest and quiet. 
Stimulants should not be given unless the collapse be very alarming. 
If reaction be ushered in by a hot skin, flushed face, and diminished 
pupils, ice to the shaven head, a smart purge, a darkened room, and 
complete rest for two or three weeks will be advisable. (See Col- 
lapse.) 



CONDYLOMATA — CONJUNCTIVITIS 



135 



CONDYLOMATA. 

Cleanliness, and the free pencilling over of the patches with solid 
argent, nit., or the acid nitrate of mercury solution, and afterward 
dusting with dry calomel, is the best treatment for the troublesome 
growths. 

Chromic acid (1 to 5 of water) speedily destroys mucous patches in 
the mouth and on the tonsils ; it must, however, be used sparingly, as 
its poisonous effects, when absorbed, are well known. 

Iodoform may be freely dusted upon those appearing on the vulva 
and about the anus, or wherever there is much moisture. 

Nitric and carbolic acids may be used as caustics, while the strong- 
est zinc chloride solution will rapidly destroy external patches, and a 
weak lotion of the same (10 grains to 1 ounce) makes a good astrin- 
gent dressing for after-treatment. 

The non-specific patches of long standing may be freely cut off with 
a knife or scissors after the appplication of the ether spray, and a sub- 
sequent application of any strong caustic will stop all hemorrhage, 
and destroys anything left by the cutting instrument. 



CONJUNCTIVITIS. 



The milder and more common form of simple or catarrhal conjunc- 
tivitis is best treated by any mild astringent lotion, as 



Or, 
Or, 
Or, 
Or, 
Or, 



R . — Zinci sulphatis 
Aquas rosas 

R . — Acid, borici 
Aquas rosas 

R . — Aluminis sulphatis 
Aquas destil. 

R . — Zinci chloridi . 
Aquas destil. 

R. — Hydrarg. bichlor. 
Aquas distil. 

R. — Argenti nitratis 
Aquas distil. 



gr. x. 
Iviij- 

gr. xxxy. 
I^iij. 

gr. iv. 

Iviij. 

gr. v. to xx. 
ifviij. 



These lotions can be best applied directly to the conjunctiva by the 
small douche glass made to fit to the margins of the orbit, and hall 
filled with the solution ; by nodding the head, the conjunctival sac is 
thorougly cleansed, and if the lids are kept open every part is brought 
into contact with the remedy. A very short course of this treatment 



136 CONJUNCTIVITIS. 

is generally sufficient. Pain and photophobia may be relieved by 
iced compresses, and the instillation of atropine or cocaine. When 
the case does not yield in a few days to astringents, the lids should 
be everted and the whole conjunctiva brushed over with the nitrate 
of silver solution; after applying this latter (10 grains to 1 ounce) the 
surface should be rapidly swabbed with solution of chloride of sodium. 
It should be remembered that this form of the affection is highly con- 
tagious, and the most careful isolation is necessary sometimes to pre- 
vent it spreading in schools. Towels, basins, soap, brushes, etc., should 
be carefully cleansed before being used by children free from the dis- 
ease. The writer has quite recently seen a large school of young 
children affected in this way. 

Strumous Ophthalmia is the name by which an affection like the 
above is known when it attacks scrofulous and badly cared-for chil- 
dren. Generally phlyctenular ulcers exist, and there is much redness, 
swelling, pain, and photophobia. Atropine gives great relief in most 
cases, though it sometimes aggravates. The use of any of the astrin- 
gent lotions already mentioned would do good, but it is often impossi- 
ble to get the little patients to tolerate their application. 

Pagenstecher's ointment — 30 grains of yellow oxide of mercury to 
1 ounce of vaseline — should be smeared across the margin of the 
slightly everted lid. Half the ordinary strength of this ointment is 
better, and the writer has seen best results from it when made of the 
strength of 8 grain to 1 ounce. 

Like all eye ointments, if not carefully rubbed smooth, the coarse 
particles will do harm by increasing irritation. For this and the pre- 
vious form of conjunctivitis dry calomel dusted into the eye with a 
camel's hair brush generally gives splendid results. It should be con- 
tinued for a considerable time after the disappearance of all mischief. 

The constitutional treatment for struma should be actively under- 
taken — good feeding, open-air exercise, cod-liver oil — and the eyes 
should not be bandaged or shaded except in strongest light. If cor- 
neal mischief results, appropriate treatment should be at once com- 
menced. (See Cornea, Inflammation of.) 

Ophthalmia Neonatorum. — Hourly washing of the eye by a 
small stream of weak astringent lotion, allowed to fall between the 
opened lids from a small piece of good sponge or piece of lint, will 
soon cut short the disease. Two nurses sit down on chairs facing each 
other. One takes the child and places it on its back, with the head 
resting upon the knees of the opposite nurse, who opens the lid with 
the fingers of her left hand, while she squeezes the lotion from the bit 
of sponge, allowing it to fall in a small stream upon the conjunctiva. 

If there be no abrasion or ulceration, by far the safest remedy to 
put into the hands of the nurse is a weak solution of alum (8 grains 
to 1 ounce), and though it is said to act as a solvent to the corneal 
cement, the writer has never seen it do the slightest harm in the large 
practice of a children's hospital. Zinc sulphate (1 grain to 1 ounce) 



CONJUNCTIVITIS. 137 

or any of the previously mentioned lotions may be used. Weak car- 
bolic acid (2 grains to 1 ounce) does very well, and also corrosive 
sublimate solution (1 : 6000). 

Another excellent plan of treatment in cases of some severity is to 
wash out the eye, as just described, with a stream of water, and then 
with a large soft camel's hair pencil swab over the inflamed conjunc- 
tiva with a solution of nitrate of silver (2 grains to 1 ouuce) every 
four hours. The lids should be smeared with vaseline iodoform oint- 
ment (1 : 20) along their margins, to prevent their adhering together. 

If there be great swelling and congestion, the conjunctiva should 
be once or twice swabbed over (when the lids are thoroughly everted) 
with a strong solution (15 grains to 1 ounce) of nitrate of silver, or 
the mitigated stick may be cautiously applied. Compresses soaked in 
iced water should be continually applied in severe cases. 

Crede advises that a drop of a solution of the nitrate of silver (10 
grains to 1 ounce) should be put into the eyes of all children imme- 
diately after birth as a preventive. The disease spreads from one in- 
fant to another. 

Scrupulous cleanliness is all that is necessary. It seems certain 
that the infection, except in some cases of face presentation, cannot 
occur in the vagina, but afterward. The face of the child should be 
washed with a different sponge and water from that used for the body. 
Atropine should be used along with the caustic when there is any 
opacity of the cornea to be noticed. When the secretion gets thin, 
reduce the strength of the nitrate of silver solution. Eserine should 
always be resorted to when ulceration of the cornea takes place. 

Ophthalmia, Purulent. — Including under this head cases of the 
previous variety which have gone on from bad to worse until a free 
discharge of pus flows from the conjunctival membrane, and including 
also the severe and dangerous cases caused by the inoculation of gon- 
orrheal matter into the eye, the treatment is to be conducted upon 
the lines already mentioned, only stronger solutions must be used. 
After washing the secretion off the membrane, the lids should be 
thoroughly everted and brushed over with a very strong solution of 
the nitrate of silver (20 grains to 1 ounce), and a little solution of 
common salt immediately dropped upon the surface to neutralize the 
caustic. Or the solid stick of mitigated caustic B. P. may be lightly 
applied, and some solution of salt dropped on afterward. Iced com- 
presses should be applied, and the caustic application renewed again 
at the expiration of twenty-four hours. If the ulceration of the cornea 
has already taken place, the same treatment will benefit it. The other 
eye, if sound, should be most carefully guarded against the possibility 
of inoculation, by bandaging over a pad of cotton wool, or in the case 
of infants by sealing the lids with collodion. In milder cases, instead 
of applying the caustic twice or oftener, the surface of the inflamed 
membrane may be dusted over with very finely powdered iodoform, or 

10 



138 CONJUNCTIVITIS. 

if there are reasons against the use of caustics, solution of bicarb, soda 
(30 grains to 1 ounce) may be tried. 

Excellent results are reported by H. Jones and E. Browne, by the 
plan of prolonged irrigation of the whole of the conjunctiva with a 
half per cent, solution of trichlor-phenolate of magnesium, with an 
irrigating reservoir. Panas' solution of biniodide of mercury was used 
in the same way, and caused less smarting and gave as good results. 
An ordinary Eustachian catheter can be substituted for the irrigating 
lid retractor. 

Croupous Ophthalmia is best treated by frequent washing out 
with solution of boric acid (20 grains to 1 ounce), or better still by 
repeated applications of solution of zinc chloride (4 grains to 1 ounce), 
or corrosive sublimate (£ grain to 1 ounce). 

Diphtheritic Conjunctivitis in the early stage must be met by 
vigorous constitutional treatment (see Diphtheria). After the estab- 
lishment of purulent discharge in the second stage the caustic reme- 
dies mentioned under Purulent Ophthalmia may be most cautiously 
used, but caustics in the first or hot stage are to be condemned, then 
iced or hot fomentations are alone admissible. 

Granular Ophthalmia, Conjunctivitis, or Trachoma. — The 
cause of the affection should be removed. Thus, overcrowding, want 
of cleanliness, smoky atmospheres, low-lying and damp habitations all 
tend to produce the disease. 

The discovery of a microbe, which accounts for the marked conta- 
giousness of the affection, suggests treatment by remedies fatal to germ 
life. Solution of bichloride of mercury (1 grain to 1 ounce) may be 
freely applied with a brush, and no further treatment will be required 
in mild acute cases save cold compresses to relieve pain, and darkened 
glasses to shade the light. 

When purulent inflammation sets in, the indications for treatment 
will be mild astringent lotions used every few hours, and should the 
discharge continue, the treatment recommended for purulent ophthal- 
mia must be employed. 

In the chronic form of the disease the treatment will be to cause 
removal of the so-called granulations before destruction of the under- 
lying membrane takes place This is best done by exciting a mild 
inflammatory action with caustics. A large crystal of sulphate of 
copper, rubbed into a suitable form, should be applied to the affected 
membrane. This very old-fashioned treatment is perhaps the most 
satisfactory of all methods of dealing with the chronic affection. It 
is better than nitrate of silver, which cannot be applied by the patient 
or nurse, and which is apt to cause staining, the application of the 
solid sulphate being, upon the other hand, easy and free from danger. 
Its use should not, however, be too long continued. It is a good plan 
to suspend its action for a time, and apply the solid mitigated caustic, 
followed by salt solution occasionally. 

In very obstinate cases cocaine may be applied, and the granular 



CONSTIPATION. 139 

membrane scarified before applying the copper sulphate. Failing by 
all these methods, surgeons have been led to produce a purulent oph- 
thalmia by inoculating the matter from the eye of an infant suffering 
from ophthalmia neonatorum, or by the instillation of fresh jequirity 
infusion (1 per cent.). The first method is obviously objectionable. 

The second, though followed generally by a violent inflammatory 
action which clears off the old disease and any pannus present, may 
leave the eye greatly improved, nevertheless, since the inflammatory 
action sometimes cannot be controlled and destroys deeper structures, 
its use should only be attempted by a specialist of experience when 
there is much pannus present without corneal ulceration. In this latter 
case, curetting of the cornea acts very well. The same remark applies 
to the operation of removing the granulations by electrolysis, or by 
excision or abscission. 

At the different stages of the treatment, the ointment of the yellow 
oxide of mercury, 30 grains to 1 ounce, may with benefit be applied in 
most cases; the red oxide does better sometimes. Corrosive sublimate 
solution may be used while the copper is suspended. This should be 
resumed as soon as the granulations became pale and flabby. Arnauts 
relies almost entirely upon the corrosive sublimate even in very old 
chronic cases, and he prefers it to all other agents, including copper, 
silver, and other astringents and caustics, and his opinion is supported 
by that of many others. He finds the corneal vascularity so rapidly 
disappears, that he thinks there must be some special action of the 
drug upon the newly formed vessels. Twice a w r eek, after cocaine, the 
conjunctival surface of the lids is brushed with a 1 : 100 or 1 : 120 
solution of corrosive sublimate, whilst a few drops of a 1 : 500 solu- 
tion are to be dropped into the eye three times daily. Any little pain 
from these drops passes off in a few minutes. 

Darier objects to the time taken up by these methods, and he there- 
fore aims at a speedier removal of the trachom- coccus by the following 
steps of a radical operation which he has recently devised : (1) Anses- 
thesia by chloroform ; (2) enlargement of the palpebral fissure ; (3) 
exposure of the entire sac by everting the lids ; (4) scarification of 
the conjunctiva by deep incisions parallel to the margin of the lids; 
(5) scraping with a Volkmann's spoon ; (6) brushing in with a hard 
brush a solution of corrosive sublimate, 1 grain to 1 ounce. 

CONSTIPATION. 

If the physician can clearly determine the cause of the failure of the 
bowel to act, and if this cause has not been long in operation, its re- 
moval may often effect a complete and lasting cure. Thus in the case 
of a person confined within a limited space from morning till night 
without open-air exercise, it is surprising to see the effect which will 
generally follow a smart walk into the open air, especially in young 
subjects. Perhaps of all the causes of constipation, none is so constantly 



140 CONSTIPATION. 

present as the state of blunted sensibility which gradually but certainly 
follows neglected calls to evacuate. This cause must be ever on the 
increase as the high pressure of modern life promises fair to remain a 
gradually increasing quantity. The importance of some engagement 
or occupation causes the patient to control the desire to relieve the 
bowel till a more convenient moment, and three things happen : 

1. The nerves of the rectum soon become less sensitive to the 
stimulus caused by the presence of the feces, and, if the disregard to 
the stimulus becomes a habit, the nerves fail to telegraph after a time. 

2. The rectum becomes dilated, and its muscular fibres weakened. 

3. The feces, remaining in the rectum longer than they should, 
undergo changes owing to absorption, and they become dry and hard, 
and more difficult of expulsion. 

The treatment here indicated is to impress upon the patient the 
necessity of going to the closet at a certain fixed hour every day and 
by patience and artificial means to get the bowel into the habit of 
emptying itself daily. The experience of nearly every one points to 
the time immediately after breakfast as being the most suitable. It is 
a common error for the physician to ■ direct a patient to go to the 
closet and strain or bear down from day to day till his efforts are re- 
warded by a painless evacuation. There are various grave reasons 
why this should not be encouraged to an undue extent ; hemorrhoids, 
prolapsus, and fissures are constantly the result. 

Owing to the formation of the ordinary water-closet seat, each 
attempt at bearing down drives the pelvis tighter into the circular 
aperture of the seat, the bevelled sides of the opening also acting as 
an inclined plane, and the result is that the skin and mucous membrane 
around the anus become stretched to such an extent that cracks and 
fissures are formed, and the writer has satisfied himself that the brittle 
and unhealthy state of the integument observed in this region is owing 
to this stretching, which is often the starting point of prurigo and 
eczematous distress. 

The modern fashion, originating in the sense of comfort and ease, 
should be corrected by the substitution of an aperture of different 
shape, and very much larger. 

Evacuation should be artificially assisted by enemata or other means 
for several mornings, until the bowel begins to show signs of respond- 
ing at the fixed hour. A cold water enema of about a tumblerful, 
injected while in the standing posture, so as only to reach the lower 
part of the rectum, is the best method of starting the intestinal tube 
to contract. Glycerin, in doses of a teaspoonful or less, injected with 
a syringe made for the purpose, acts powerfully by stimulating the 
membrane, but its present popular professional reputation as a remedy 
for constipation rests altogether upon a misconception of its advantages. 
By its powerful stimulation of the cOats of the rectum (partly through 
its hygroscopic property), it ultimately blunts the sensibility of the 



CONSTIPATION. 141 

rectal nerve filaments to smaller stimuli, and if solely relied upon the 
end will be worse than the beginning. 

Its value seems to be clearly like that of most purgative remedies ; 
it is of use in tiding over constipation until other means have time to 
act. The enema may be substituted by a glycerin suppository, which 
acts equally well. 

These suppositories afford, perhaps, the most convenient of all 
known methods of overcoming temporary constipation. Often within 
five minutes, and sometimes immediately, a copious and painless motion 
may be experienced after their introduction, and in affections like 
typhus or typhoid fever their action leaves nothing whatever to be 
desired. In hemorrhoidal conditions and in cases of anal fissure, how- 
ever, their use sometimes may bring on a very acute attack of pain 
and tenesmus. The glycerin soap suppositories act well, but the writer 
has generally obtained all the advantages claimed for glycerin by in- 
serting within the internal sphincter a piece of ordinary soap shaped 
with the knife to suit the purpose, and this he has tried in cases of anal 
ulcer without any ill effects whatever, save momentary smarting. 
Both these plans, glycerin and soap, do splendidly with children. 

Should there already be accumulations of feces in the rectum and 
colon for some time, they must be removed, and for this purpose ordi- 
nary purgation by the mouth is not to be thought of. A tepid water 
enema should be given when the patient is lying upon the left side, 
with the view of getting the fluid beyond accumulation ; two or three 
quarts, if slowly thrown up, are safe, and generally effectual. 

Castor or olive oil may be administered along with the water with 
great advantage. It is useless to pour the oil into the water, where it 
floats, and is not injected into the bowel till the very last. The nurse 
should lift the end of the enema pipe (lying in the water), and put it 
into a cupful of the oil, and continue the operation as before without 
the removal of the other end from the rectum. After pumping up 3 
or 4 ounces or more in this way the end of the pipe is taken out of the 
oil and dropped into warm water again, and the pumping gently con- 
tinued till the patient cannot tolerate the introduction of any more 
fluid, when the motion will occur. To remove lodgments from the 
colon several enemata may be required, and should the mass be above 
the reach of the finger, weeks may be spent in pumping it out, though 
this is decidedly exceptional. Should the mass be low down it may be 
broken up with the handle of a spoon or scoop, and removed piecemeal. 
Injections of oils, gruel, white of eggs, linseed infusion, and various 
other emollients are used. Recently a writer urges that brewer's yeast, 
when injected, breaks up, and causes the rapid disintegration of the 
impaction, and as it is harmless it should have a trial. 

Electricity has been recommended by Hammond, who introduces 
the negative electrode within the sphincter for the treatment of chronic 
constipation. 

An apparently similar line of treatment is that used by Cleveland, 



142 CONSTIPATION. 

who forcibly stretches the sphincter. This causes it to offer only pas- 
sive resistance to the feces passing from the colon, while it closes suffi- 
ciently to check involuntary defecation. 

Having then got the intestinal tract cleared in a case of chronic 
constipation, the physician's next attempt is to assist the patient in 
having a daily evacuation of the bowels, or if an evacuation every 
second day has been the patient's life long habit when in health, the 
effort should be to restore this habit, and not to attempt to improve 
upon nature. 

Much can be done, as already suggested, by urging the patient to 
take a morning open-air walk if his habits have been sedentary. 
Unfortunately, in many instances, the class of patients to whom this 
would be valuable have little opportunity for walking, and the haste 
to reach their offices in the city only permits them to indulge in their 
usual omnibus or railway trip. To such, a half-hour's tricycle ride 
will be followed by splendid results. 

Much can be done by diet. It is generally the small eater or spare 
liver who is the victim of chronic constipation, and often if such a 
one, from any cause begins to eat almost any sort of food in larger 
quantity than is necessary for the maintenance of health, the consti- 
pation disappears. In prescribing a dietary, foods which leave a bulky 
residue should have the preference. Brown bread, whole-meal bread, 
or any of the valuable bran breadstuffs placed within the reach of 
every one by the various food reform organizations are of great use. 
Oaten meal made into porridge, and taken at bedtime or before the 
ordinary breakfast, is the remedy which keeps many folk in health for 
years. 

Vegetables and ripe fruit should be taken freely, and an orange 
eaten in the morning while dressing, answers well in some cases. 
There is nothing better than a good supper of boiled Spanish onion, 
and the writer has treated obstinate cases of constipation by this 
means alone, with very satisfactory results. 

To patients who can bear a good sized spoonful of pure olive (salad) 
oil every morning after breakfast, it is a valuable laxative and food. 
The writer has noticed that it is not well borne by the plethoric, or by 
lean folk with dark skins. The pale washy-looking, blue-eyed, seden- 
tary, thin subject gets much benefit from it or from cod-liver oil when 
taken once a day in one large dose. 

Figs and prunes are serviceable, but even children grow weary of 
their lusciousness. Stewed prunes do well for a short time. 

It is often a good thing to advise the patient to become a vegeta- 
rian for a time, and if he takes to the practice and makes a " fad " of 
it, his constipation, as a rule, disappears. 

A diet consisting largely of boiled eggs, is sometimes the cause of 
the most obstinate constipation and accumulation of feces. 

The Matlock system of wearing a cold water compress over the 
abdomen in the morning is of use, and massage or kneading of the 



CONSTIPATION. 143 

abdominal muscles may be tried in very sluggish subjects, or even 
smart friction over the abdominal walls with a coarse, warm towel for 
five minutes on rising, followed by a large drink of cold water and a 
smart cold shower or plunge bath, may do more good than medicines. 

Electricity — a weak continuous current, with one pole on the spine 
and a large wash leather or sponge electrode moved about over the 
lumbar and hypochondriac regions, or a smart interrupted current 
may be used with advantage in the same way. A method of effecting 
the emptying of the colon by electricity has already been mentioned, 
but the writer would be slow to try it. 

By a careful attention to the above methods, the physician will find 
that most of the cases of chronic constipation will be successfully 
combated without having to resort to the long list of purgatives in 
daily use. As a rule, active purgation should not be permitted, and, 
in many of the cases seeking relief, continual purgation indulged in 
for fancied ills will be found to be the cause of the constipation. 

To increase the muscular and nervous tone of the bowel, and, at the 
same time, to increase the intestinal secretion so as to bring the motions 
to a healthy state of consistence, should be the objects aimed at in the 
treatment of chronic constipation with drugs. 

Of the selection of purgatives there seems to be practically no end, 
and only a brief reference to the most valuable can be attempted. 

Cascara sagrada, the comparatively new remedy, comes first in 
value, and when all the dietetic and previously-mentioned plans have 
failed, the patient should be placed upon small doses of the liquid 
extract. It may be given in various ways. One moderate dose at 
bed-time, the treatment not to be commenced till the existing consti- 
pation is for the moment corrected by some brisk purgative, is the 
most successful plan. Beginning with a nightly dose of 30 minims, 
in a few days the physician will obtain some idea of the dose suitable 
to the individual case, and the initial quantity is increased or 
diminished accordingly. 

The object to be clearly aimed at is to avoid purgation, and to give 
the remedy in such a dose as wall secure one soft, natural motion 
every morning. The amount necessary to produce this result varies 
widely in different individuals, and in the same individuals at different 
seasons of the year. 

There is the greatest difficulty in getting patients to graduate the 
dose themselves, and after a few weeks they stop the cascara altogether, 
through carelessness, or a belief that they are cured of the constipa- 
tion and when the bowels return to their old habit, a large dose 01 
cascara is taken as a purge. This is certain to be followed by worse 
constipation, and thus the remedy is set down as useless. The physi- 
cian should be prepared for this, and should insist upon a two months' 
course at the very beginning of the treatment. 

Another method is to give the cascara three times a day, after meals, 
in a dose equivalent to about one-third of the nightly dose. Thus, 10 



144 CONSTIPATION. 

minims may be given immediately after breakfast, luncheon, and 
dinner. 

No matter which plan be adopted, after a few weeks the dose should 
be gradually diminished, still, however, taking enough to produce the 
healthy, natural morning motion, as if no purgative had been admin- 
istered. At the end of a period, varying much in different cases, the 
remedy may be occasionally suspended for one day, and finally, in a 
few months in some cases, it may be permanently stopped. 

The cascara may be given alone, or combined with some of the 
remedies about to be mentioned. 

The B. P. C. cordial or elixir (1 : 2?) is a very good preparation in 
doses of about 1 teaspoonful. The fluid extract may be given with 
the fluid extract of liquorice. 

The writer prefers the following : 

R. — Ext. cascarse sagradse fld. 3ij. 

Tin ct. nucis vomicae -. . . . . . giij. 

Tinct. belladonna? fol # 5iij. 

Glycerini . . . . • . q. s. ad %iv. — M. 

S. — Take a teaspoonful every night and morning for four days then every 
night. 

Sometimes the cascara is given before meals, and capsules containing 
any requisite dose may be had easily from any chemist, but, though 
elegant and effective, the dose cannot be easily regulated when the 
capsular form is used. The pilular extract may be given, but the 
fluid is more certain and uniform in its action. A new tasteless fluid 
extract is now prepared, and it is said that the extraction of the bitter 
substance in no way interferes with its efficacy. 

Aloes comes next to cascara in value in the treatment of chronic 
constipation, and it is possible, in some years hence, that it may regain 
its old position at the head of the list. Like its newer rival, if judi- 
ciously administered, the dose need not be increased, while, in many 
cases, it may be diminished, and finally withdrawn as the constipated 
habit becomes cured. It is best given in combination with other 
laxatives or cathartics as it is slow in its action, and, when given in 
small doses, does not soften the motions much, but stimulates the peri- 
staltic movement. It is a tonic, and very markedly increases the 
quantity of the biliary secretion. 

Its action in chronic constipation is very materially increased by 
combining with it sulphate of iron, and Dr. Spender's famous pill is a 
splendid combination. 

R. — Ext. aloes aq g' r -j- 

Ferri sulphatis gr. ij. — M. 

Fiat pilula. (Make 50 of such pills.) 

S. — Take one three times a day for seven days, then one twice a day for a 
fortnight, then one every night. 



CONSTIPATION. 



145 



If the constipation be associated with amenorrhea, the combination 
of aloes with iron is the best possible treatment. 

Much conflicting opinion has been given about aloes in the treat- 
ment of constipation when associated with haemorrhoids, and the 
matter may be safely disposed of in this way : Large purgative doses 
of aloes often seriously aggravate haemorrhoids when present, while 
small laxative doses generally relieve and produce decided curative 
effects ; and good results have been obtained by excellent authorities 
who treat haemorrhoids exclusively by small doses (1 grain) of the 
extract of aloes given night and morning. 

The compound decoction of aloes is a most unsatisfactory laxative 
in chronic constipation, and though of the greatest value in other intes- 
tinal disorders, it is not to be depended upon, as it is almost impossible 
to regulate the dose so as to produce uniform results, and frequently it 
causes constipation. (See fifth edition of Pharmacy, Materia Medica, 
and Therapeutics, page 354.) 

The best results with aloes are obtained by the old-fashioned dinner 
pills, in which a small dose of aloes is combined with iron, ipecac- 
uanha, capsicum, nux vomica, myrrh, belladonna, or hyoscyamus, and 
given immediately before or after dinner. 

The following is an excellent combination 



R . — Ext. aloes soc. . 

Ext. nucis vomicae . 

Pulv. ipecac. . 

Pulv. capsici . 
Fiat pilula. (Make 24 of these pills. 
S. — Take one each day after dinner. 

Sir Andrew Clarke uses this formula 



gr. ss. 
gr. ss. 
gr. ss. 



M. 



gr. ss. 



M. 



R . — Ext. nucis vomicae "] 
Ferri sulphatis 
Pulv. myrrh se 
Pulv. saponis 
Aloin J 

Fiat pilula. 

The quantity of aloin is to be increased or diminished according to 
the effect produced upon the bowel. 

Owing to the length of time aloes takes in acting, it is a mistake to 
give small doses at bed-hour, because they will produce no effect upon 
the morning evacuation. 

Trousseau found the best results in the treatment of chronic consti- 
pation to follow the administration of 

Belladonna. The green extract in doses of i to h grain given 
at bedtime, alone or with as much extract of nux vomica, may be 



146 CONSTIPATION. 

tried, or belladonna may be given with any laxative in a dinner pill, 
when it will not only strengthen the muscular contractions of the 
bowel, but will to some extent prevent griping. The tincture, in small 
doses, is a very excellent treatment for the constipation of infants and 
children. 

Colocynth, in small doses, is a valuable remedy, and the best prep- 
aration is the Prussian pharmacopoeial tincture, in doses of 10 minims 
after dinner or a larger dose at bedtime. The compound extract may 
be given as a dinner pill in doses of 2 grains. A valuable combination 
is the following : 

H • — Ext. colocynth. comp. . . . . . . gr. xxv. 

Ferri arsen. . . . . . . . . gr. j . 

Ext. belladon. . . . . . . . . gr. viij. — M. 

Divide in pil. no. xx. 
S. — One after dinner. 

In a few weeks the colocynth is to be. diminished by one-half, and 
in a few weeks more it may be omitted altogether, and extract of nux 
vomica put in its stead. 

Rhubarb, though much used and often swallowed for many years 
by constantly constipated patients, is not a good remedy. In the 
writer's experience its tendency in chronic constipation is not curative, 
and the reason why so many old folk stick to it is because once they 
get into the way of using it they cannot well do without it. 

Podophyllin is much more valuable in the treatment of acute con- 
stipation where a satisfactory brisk purge is required, nevertheless it 
is useful in the chronic constipation of bilious subjects, and Quinlan 
speaks highly of the crug in the treatment of this condition. It may 
be very advantageously given in combination with belladonna. 

ft— Ext. podophyl. M 3yj. 

Tinct. belladon. . . . . . . . ' giv. 

Tinct. zingiberis gvj. — M. 

S.— Take twenty drops every night with a little sugar. 

Nothnagel recommends the following formula as a laxative in chronic 
sluggishness of the bowel : 

R. — Podophylli resinse gr. ivss. 

Ext. aloes aq gr. xlv. 

Ext. rhei. gr. xlv. 

Ext. taraxaci q. s.— M. 

Divide in pil. no. xl. 

8. — One, two, or three at bedtime. 

Euonymin in pilular form acts much in the same way. 



CONSTIPATION. 147 

Castor oil, in small doses, has been given for long periods with 
advantage. Thus in the chronic constipation of pregnancy it is the 
best remedy in morning doses not exceeding one drachm, and may be 
taken with impunity all through. 

Saline purgative waters, as Friedrichshall, Carlsbad, Hunyadi 
Janos, Pullna, etc., are very valuable as occasional adjuncts to the 
aloes or cascara treatment, and they are invaluable in the management 
of occasional constipation, but unless the above rational line of treat- 
ment by small laxative doses fail, their constantfuse is not likely to be 
followed by cure of the ailment if of long standing. The Friedrich- 
shall is the best, and should be given in wine-glassful doses with warm 
water early in the morning before getting up. There is no better drug 
than this at the beginning of a course of treatment for chronic consti- 
pation, and its occasional morning administration, following aloes or 
cascara given the previous day, is attended with excellent results. 

Senna, jalap, scammony, gamboge, croton oil, epsom salt, 
and mercurials are not available for the treatment of chronic, though 
valuable for the relief of acute or occasional constipation. 

Tamar indien is an excellent remedy, and when administered w r ith 
care to regulate the dose, is a very successful method of treating chronic 
constipation in patients whose feeble health or chronic ailments confine 
them to the house for the greater part of the year. It produces very 
large, almost solid motions, and its action is not followed by any ten- 
dency to constipation, and the dose can be easily diminished by the 
patient. 

Sulphur is a good drug for the relief of chronic constipation, and 
may be given in the morning before breakfast mixed with a spoonful 
of orange marmalade, and the compound powder of liquorice is a pala- 
table laxative for children. 

Alum has been used as a remedy for chronic sluggishness of the 
bowels, and it is, doubtless, of great value in the constipation of lead 
colic ; but, from its very marked astringent effect, the writer would be 
very slow to continue its use in ordinary cases of habitual constipation. 
It has been given in 3 grain doses with as much bismuth in pilular 
form. 

COCCULUS, GUAIACUM, MUSCARINE, PHYSOSTIGMA, STILLINGIA, HY- 
DRASTIS, many eclectic remedies as baptisin and iridin, collin- 
sonia canadensis, and many other cathartics have been, from time to 
time, used with some advantage in the treatment of chronic constipa- 
tion. The writer has never felt called upon to use any of them, as he 
always found the condition to yield to the older and better known 
remedies. 

For the constipation of children, many of the previously mentioned 
drugs are not suitable. In infants, the cause of the constipation, when 
it exists, is generally bad feeding, and it generally disappears when this 
error is corrected, The best drug for infants and young children is 
castor oil, and a daily very small dose — half a teaspoonful — generally 



148 CONVULSIONS. 

removes the condition. The writer has given cascara to young chil- 
dren with very obstinate bowels, with very satisfactory results ; 5 
minims of the fluid extract may be given every night, and the dose 
regulated as in the case of adults. 

Glycerin suppositories, containing 90 per cent, pure glycerin, 
when inserted into the rectum, act with great promptness and thorough- 
ness. Ordinary injection of 20 minims of glycerin acts satisfactorily, 
and may be used daily. This remedy is not objectionable in the case 
of very young children, as the writer thinks that the act of evacuation 
in them is more dependent upon the state of the great intestine higher 
up than the rectum, and the fact of accustoming the rectum to a smart 
stimulus from day to day, does not appear to blunt its sensibility so as 
to interfere with the act of defecation after the injections are stopped, 
as appears to be the result in adults. 

Soap suppositories, made by cutting a small fragment of hard soap 
into conoidal form, and inserting it into the rectum, act also very well. 

Compound liquorice powder, or 2 to 5 grain doses of sulphur, may 
be given for considerable periods with advantage. 

Manna is a safe laxative for very young children, and may be given 
freely for a long time till the constipated habit disappears. 

Injections of tepid water, 5 to 10 ounces, may be given occasionally 
to young children, and 3 to 6 ounces in cases of congenital constipation. 
It is needless to say that in these cases a very careful examination of 
the anus and rectum is essential when the bowels remain obstinate for 
any length of time in infants or very young children. 

To acute attacks of constipation occurring in a person otherwise 
healthy, aud where there is no abdominal obstruction, it will be seen 
that the foregoing remarks do not apply, and the treatment for such 
attacks is a smart purge. Any of the remedies already mentioned may 
be given in large doses. The old-fashioned method is the best, of giving 
at night a combination of cathartics, whose slow action upon different 
parts of the intestinal tube is " overtaken" by a smart dose of a saline 
early in the morning. Thus, 5 grains of mass, hydrarg. and 5 grains of 
ext. colocynth. comp., taken at bed-hour, and 2 ounces of black draught 
early in the morning, is a very efficient purge for robust men. 

It must not be forgotten that diarrhoea is sometimes, especially in 
elderly people, caused by a mass of scybalse lodged in the colon, and 
the proper treatment in such a case is to give a purge and commence 
with large enemata of tepid water, given while the patient is placed 
upon his left side. Should the mass be high up in the colon, the 
patient should be placed upon his knees and elbows, and afterward 
turned over upon his right side, so as to assist the water by gravitation 
to reach toward the ileo-csecal valve. 

CONVULSIONS. 

A correct idea of the treatment of convulsions can only be obtained 
from a knowledge of the different conditions of which the convulsions 



CONVULSIONS. 149 

may be the only symptom. Thus the presence of a mass of round 
worms in the intestinal canal of a child will call for a purgative and 
santonin. (See Ascaris.) The convulsions arising in a patient suffer- 
ing from advanced renal affection will demand the active treatment 
necessary for ursemic poisoning. (See Bright's Disease.) Epileptic 
convulsions will be best prevented by bromides, etc. (See Epilepsy.) 
In the same way the reader will find under Hysteria, Tetanus, Poison- 
ing by Strychnine, Teething, Apoplexy, Alcoholism, Puerperal Con- 
vulsions, etc., the appropriate remedies mentioned by which the con- 
vulsions may be prevented or modified or rendered less frequent. 

If called to see a patient laboring under an attack of convulsions 
(without any apparent cause demanding immediate attention, such as 
pregnancy or ursemia), the physician will have considerable difficulty 
in preventing himself from acting under the impulse "that he must 
do something." The position of "masterly inactivity " is the safest 
as regards drugs in a situation of this sort, where at the moment little 
can be determined about the causation or pathology of the symptoms. 
The patient should be placed in bed upon his back with his head and 
shoulders slightly raised, and all constrictions about the neck, thorax, 
or abdomen removed. If the tongue be protruded, and in danger of 
being wounded by the closure of the teeth, a lemonade cork may be 
inserted between the upper and lower molar teeth on one side. Unless 
the convulsive movements be severe and liable to cause contusions of 
the limbs or scalp, restraint should not be resorted to. In a series of 
rapidly succeeding attacks the vapor of nitrite of amyl may be judic- 
iously employed. Chloroform or ether may be administered upon a 
sponge, or chloral hydrate may be given by the rectum. Heroic meas- 
ures, like bloodletting, or the instantaneous blistering of a large sur- 
face of the body are wholly unjustifiable. In puerperal cases blood- 
letting may be indicated. 

Infantile convulsions. — The routine plan of scarifying the gums in 
every case of convulsions occurring in young children, should be 
strongly condemned. The tough cicatrix forming over the iucisions 
afterwards, generally is the source of serious future trouble. The 
writer has seen the leathery gums of infants who had been subjected 
to wholesale scarifications months previously for supposed delayed 
dentition, when the cause of the convulsions was probably a mass of 
curd in the intestines, the result of indigestible cow's milk. Some- 
times, when the tooth should be above the gum, these old, dense cica- 
trices so hold it down, that the only course is to snip a piece out of the 
cicatricial tissue with scissors or a knife. 

Called to a case of infantile convulsions between the fifth and thir- 
tieth month, the writer, after thoroughly disinfecting his index finger, 
passes it into the infant's mouth and feels for any prominences over 
the line of the teeth, and if any tooth feels to be very near the sur- 
face, he scrapes through the tissue of the gum till the cusp of the tooth 
is felt grating against the edge of the finger nail. The little operation 



150 CORNEA, INFLAMMATION OF. 

is almost painless if the finger nail is sharp, and healing over of the 
lacerated wound never occurs. 

Bromides are the remedy for convulsions of this class, and may be 
safely administered in all cases where there is reason to suspect a 
repetition of the attack in children or adults. A good formula for an 
infant of one year old is — 



H- — Ammonii bromidi . . . 


• • • M- 


Spt. setheris nitrosi 


• 3J- 


Chloral 


. gr. ix. 


Syr. aurantii flor. .... 


.■'.,; ^ss. 


Aqiu? cinnamom. .... 


ad ,^iij. — M 


S. — A teaspoonful every two hours. 





A warm bath is often efficacious in arresting the fit in an infant or 
young child, a mustard and wheaten flour poultice (equal parts) may 
be placed over the nape of the neck. It is always advisable to clear 
out the bowels with a smart purge as soon as the patient can swallow. 

For the convulsions coming on during the progress of brain diseases 
and cerebral tumors, large doses of the bromides, combined with 
iodide of potassium, are indicated. 

CORNEA, Inflammation of. 

For inflammations of the cornea following extensive conjunctivitis, 
and ending in suppuration or ulceration, the indications are to relieve 
pain by the instillation of atropine, or, if there be much tension or 
danger of perforation, eserine should be employed. To secure abso- 
lute rest, the eye should be carefully bandaged, or a large shade 
placed over both eyes. In the inflammatory stages, with much photo- 
phobia and pain, astringent and stimulating applications must be 
avoided. Warm fomentations, and belladonna extract rubbed up 
with glycerin, may be smeared over the brow and outside of the lids. 

Should there be much secretion, the constant use of a mild unir- 
ritating antiseptic lotion must be kept up. Boric acid is the safest 
and most efficacious (40 grains to 10 ounces). Bichloride of mercury 
(2 grain to 10 ounces) may be used. 

Where the photophobia is intense, a free division of the outer 
canthus may be made, and leeches to the brow often afford considerable 
relief. 

When the acute stage is over, much benefit will be obtained by 
stimulating treatment. This may be carried out before pain subsides 
if atropine be constantly used. The best application is the yellow 
oxide of mercury ointment, but it is too often used of a strength that 
aggravates the affection. 8 grains to 1 ounce of vaseline is gene- 
rally enough for all purposes, and sometimes half this strength will be 
found to answer better. A minute portion of the ointment may be 
inserted inside the lids twice a day. 



CORNEA, INFLAMMATION OF. 151 

Calomel, dusted inside the lids once daily, often acts with great 
rapidity, and causes the ulcers to take on new action and induces rapid 
granulation. Seldom will nitrate of silver be required. In large 
pustules or sluggish ulcers, a mixture of cocaine (8 per cent.) with 
atropine solution relieves pain and tension, and mitigated caustic may 
be lightly applied to the ulcerated spot with very marked benefit. 
Better still, after the instillation of cocaine or the use of a cocaine 
disc, a little of the nitrate may be applied in solution (10 grains to 1 
ounce) with a fine camel's hair brush, confining the application strictly 
to the ulcerated spot. This method may even be employed for deep 
ulcerations of the cornea if perforation do not threaten, and if there be 
no iritis. Eserine may be freely used in such cases. 

In very chronic cases, a seton above the temple or behind the ear, or 
blisters in the same locality prove useful. When the ulceration is 
caused by the presence of granular lids, this condition must be met by 
proper treatment. (See Conjunctivitis.) Retton uses the thermo- 
cautery to corneal ulcerations. 

Ford resorts to peritomy in troublesome, ulcerative, strumous, or 
suppurative keratitis, upon the principle that as the cornea receives 
its blood supply from the conjunctiva, the local depletion consequent 
upon a division of its vessels and of the loops which surround its cir- 
cumference, tends to promote a healthy reaction and an absorption of 
stagnant cellular elements. 

Walker has introduced a new operation under the name of perike- 
rotomy, or "cutting around the cornea" in these cases; he makes a 
series of short incisions at the base of the cornea. 

Internal treatment is of the greatest value, and constitutional 
measures must be employed from the beginning. Thus, in the phlyc- 
tenular form, as in strumous ophthalmia, of which it is generally a 
part, the treatment directed under conjunctivitis must be carried out, 
and an early change of air and scene is often followed by marked 
benefit. 

When atropine, eserine, and cocaine fail to give satisfactory relief to 
pain, the remedies found useful in neuralgia of the affected nerve may 
be employed. 5 grain doses of butyl chloral every two hours for 4 
doses may be given. 30 grains of chloride of ammonium, or 8 minims 
of the gelsemium tincture every two hours may be administered. In 
severe cases, especially in elderly patients with serpiginous ulceration, 
the free administration of stimulants with sal volatile in decoction of 
cinchona (40 minims in 1 ounce)., must be attended to. 

If the inflammatory action extends and hypopyon form — i. e., pus 
appearing in the lowest part of the anterior chamber — if its absorption 
does not follow upon the continuance of the above treatment, a free 
incision or an iridectomy must be made ; if only an incision be decided 
upon, it must be re-opened daily till the secretion of pus ceases. 

Chronic or interstitial keratitis almost always depends upon inherited 
syphilis, and in addition to the remedies for the relief of pain and 



152 CORNS AND CALLOSITIES. 

photophobia as mentioned above, the internal administration of mer- 
cury must be pushed short of producing salivation. After acute symp- 
toms subside, the yellow oxide of mercury ointment (1 grain to 1 
drachm) should be daily applied. 

CORNS AND CALLOSITIES. 

By the removal of the cause, L e., friction, or intermittent pressure 
produced by tightly fitting boots, the corn will soon disappear. The 
presence of corns, in many cases, is owing to the boots being too large, 
the friction caused by the skin of the foot rubbing against the leather 
in walking is enough to produce painful corns. Children frequently 
have their boots made too long, in order to allow for the growth of the 
foot during the wear of the boot. The result is that they get into the 
habit of strongly flexing their toes in walking, to prevent the slipping 
up and down of the foot inside the boot. The result is, corns appear 
on the upper surface of the phalangeal joints, and deformity of various 
kinds results which last during life. 

The first indication, in the treatment of these conditions, is to obtain 
properly fitting boots. (See Bunion.) 

The corn should be pared with a sharp knife, and if skilfully done, 
it can be entirely removed at one operation, but this requires skill and 
much practice. 

After the removal of the thickened epithelium, if the corn cannot 
be cut entirely out, a little glacial acetic acid may be applied with a 
bit of wood (the end of a match), and after the superficial film peels 
off, the application can be renewed till the diseased cuticle disappears. 
Nitrate of silver is painful, liable to be followed by inflammation and 
lameness, and should not be used. 

The favorite remedy is salicylic acid. It is the basis of nearly all 
the corn cures in the market. It appears to possess the strange pro- 
perty of only dissolving or acting upon the diseased epithelium, having 
no effect upon healthy tissue. 

The usual formula is — 

R. — Acidi salicylici 3J. 

Ext. cannabis ind gr. x. J 

Collodii flexilis ^j.— M. 

S. — To be daily painted over the corn. 

Soft corns may be best treated by the separation of the opposing 
surfaces with felt or amadou plaster, with a circular hole cut in the 
centre. This hole may be filled with dry salicylic acid. 

Rosen successfully treats corns, warts, and callosities in the following 
manner : The growth or patch having been well moistened with an 
antiseptic solution, is thickly covered over with salicylic acid. Upon 
the top of this is placed several layers of moistened boric lint, and over 
all a piece of gutta-percha tissue and a bandage. At the end of five 



COUGH. 153 

days, when the dressing is removed, the thickened epidermis easily 
peels from the subjacent structures. 

Unna treats sub-plantar corns by painting a broad ring of glycerine 
jelly around them with a stiff brush. When the jelly has firmly set, 
the interior of the riug is filled with a circular piece of strongest 
salicylic plaster (salicylic acid, 40 ; creasote, 40), and the whole covered 
up with two layers of glycerine jelly, and when dry a small pad of 
cotton wool. This dressing will last for a week, and may be renewed 
till the horny layer of the epidermis is entirely removed. 

Chromic acid, iodine, moxas, and caustics of various kinds have 
been employed, but salicylic acid seems to leave nothing to be desired. 

CORYZA- See Catarrh and Bronchitis. 

COUGH. 

Under Bronchitis the treatment of cough is discussed, but the physi- 
cian will meet with many cases where a persistent dry cough or bark 
is the only symptom present, and where the most careful examination 
fails to discover any abnormal physical sign in the lungs or air- 
passages. 

To successfully treat such cases it is obvious that the cause of the 
cough must, if possible, be ascertained. If there be any reason to 
suspect from the history of the case, or from a careful reasoning from 
all the available data that there is any latent pulmonary mischief pres- 
ent, the ordinary sedative remedies before mentioned may be employed. 
Thus the hacking, short, dry cough of early phthisis may be traced to 
its cause, should there be a subfebrile temperature, marked loss in body 
weight, and a bad family history with unfavorable surroundings, and 
the proper treatment will be easily indicated, though no expectoration 
or physical sigus be present. In dry catarrh of the bronchial tubes of 
large size, though the writer has seen many such cases where no rale 
or physical sign existed, 'nevertheless the presence of some small quan- 
tity of tenacious or inspissated mucus or muco-purulent secretion at 
some time or other will be found to clear up the case. The treatment 
in such a case must include more than mere sedatives 'or palliatives. 
The dry bronchial surface must be stimulated so as to cause the pour- 
ing out of a secretion of liquid consistence, after which often the cough 
practically ceases. 

The injurious administration of sedatives and narcotics in a hap- 
hazard way in bronchitis has already been mentioned, but the physician 
must not err in the other extreme, especially as incessant, violent, or 
spasmodic attacks of cough without any expectoration may in time 
lead to serious pulmonary trouble. 

Excluding, then, all cases of cough having their origin in bronchitis 
or laryngeal inflammation or diseases, it may be found that the throat 
is the seat of the irritation. Acute, chronic, or granular conditions of 
the pharyngeal mucous membrane may produce incessant coughing. 



154 COUGH. 

Elongated uvula, enlarged tonsils, polypi, and other growths at the 
back of the posterior n ares may call for appropriate local treatment. 

For the treatment of the reflex cough accompanying catarrhal sore 
throat, there is no remedy so effectual as a spray of the following, 
which may also be used as a gargle : 

R. — Acidi carbolici gj. 

Pulv. sodii bor. . . ^j. 

Cocainse hydrochlor. . . . . . . . gr. xij. 

Glycerin! purif. . . ^ ss. 

Aquse rosae ad *^xij. — M. 

S. — To be used as directed. 

The inflamed membrane can also be treated by chlorate of potash, 
nitrate of silver, alum, tannin, or other appropriate remedy. 

Ear coil gh unquestionably is to be met with, and unless the diagnosis 
be correctly made there is little probability of the cough being relieved 
by drugs. A careful examination will reveal some irritation or foreign 
body in the meatus. In the case of children, peas, beads, etc., may be 
found ; and in adults, plugs of dried wax. The wax is more likely to 
give rise to cough if partially loose in the passage, and sometimes the 
movements of the jaw in eating or speaking may so disturb the mass 
that cough results at these times. The removal of the foreign body 
by syringing is generally followed by instant relief. 

In infants the advent of each tooth is sometimes heralded by a smart 
spasmodic cough, which stops when the crown is through the gum, and 
in older patients the removal of a painful or carious stump has been 
sometimes followed by the cessation of a cough that has been a source 
of anxiety for a long time before. 

Liver diseases (abscess and calculi) have been the cause of cough, 
and in one case known to the writer a bilious attack, resulting from 
indiscretion in eating, always brought on a severe, spasmodic, barking 
cough, relieved or removed by a smart purge. 

The stomach cough has been long recognized, and yields to remedies 
which cause evacuation of the gastric contents, or to sedatives like 
bismuth, codeine, or hydrocyanic acid. Gout may be ushered in by a 
severe cough, which is relieved when the paroxysm localizes itself, and 
the presence of foreign irritants in the intestinal canal — as round 
worms, fruit seeds, etc. — may cause cough in children, which yields to 
a smart purge. 

Brain mischief, involving [the "'respiratory centre, is sometimes the 
origin of cough, and hysterical cough is commonly met with. It should 
be treated by antispasmodics like asafoetida and valerian. 

Severe spasmodic cough, arising from almost any cause, is always 
benefited by large doses of the bromides, especially by the bromide of 
ammonium. Chloroform, in moderate doses (5 minims), is a powerful 



CRAMP — CROUP. 155 

sedative in most cases, and chloral hydrate, in small oft-repeated doses, 
will allay cough when the cause cannot be removed. 

Gelsemium, grindelia, conium, and sanguinaria may be used like 
morphine and codeine, to lessen the sensibility of the respiratory centre. 

Sir Andrew Clarke believes that the very troublesome affection 
known as the barking cough of puberty, occurs in over-fed or too often 
fed children. He insists upon a simple but liberal dietary, arranged 
into three, or at most four meals a day, active out-door exercise, early 
hours, and general discipline. Locally, he uses glycerin of borax with 
oxychlorate of bismuth and morphine; or, the same mixture with 10 
per cent, of cocaine instead of the morphine, brushed over the whole 
interior of the throat after each meal, and at bedtime. 

Internally, he uses the syrup of bromide of iron and quinine, with 
small doses of arsenic. When this fails, he gives a pill containing re- 
duced iron, valerianate of zinc, belladonna, and nux vomica, pushed 
till the physiological effects of the belladonna show themselves.- 

CRAMP. 

The very painful tOnic spasm which commonly affects the muscles 
of the calf of the leg, often calls for treatment. Smart friction may 
be employed over the contracted muscle, and, by a voluntary effort, 
the opposing muscles may be thrown into firm and prolonged action, 
which soon relieves the spasm. By tying an elastic band, like 
Esmarch's, tightly round the thigh, sometimes the cramp yields at once. 

CRETINISM. 

The first thing to do is to make a complete change in the environ- 
ment of the patient. Removal to a dry, elevated situation is essential ; 
a mountain atmosphere, with a porous soil, if possible, should be 
selected. Most of the day should be spent in the open air in gentle 
exercise, and a liberal diet of milk, with plenty of fresh animal food 
and a moderate amount of fresh vegetables, may be advised. Cod 
liver oil, Parrish's syrup,' phosphate of lime, lactophosphate of lime, 
with malt extract, and most painstaking and persevering efforts to 
inculcate a higher moral and intellectual training, and to guard against 
the supremacy of the lower instincts, may do much to strengthen moral 
control and improve the mental capacity. 

CROUP. 

Any remarks about the treatment of croup must be valueless, unless 
it be made clear which of the conditions embraced under this mislead- 
ing name is prominently before the mind of the writer when discussing 
the question. In the first place, the affection known as laryngismus 
stridulus, and unfortunately wrongly called false croup — a purely ner- 
vous disease, not associated with any laryngeal inflammation — is not 
referred to here. Its treatment will be mentioned under its own name. 



156 croup. 

Acute laryngitis, which at the bedside can be differentiated from the 
varieties of croup, is also left out of consideration for the present. 

There remain subject to further explanation two distinct affections 
at least — known under the common names of false croup and true 
croup. About the first (or false croup) there should be little difficulty. 
It is spoken of as false croup, spurious croup, spasmodic croup, inflam- 
matory croup, stridulus laryngitis, spasmodic laryngitis. (Some of 
these names are unfortunately applied to laryngismus.) In the great 
majority of cases, where the services of the physician are urgently 
demanded for the relief of croup, it will be the spurious or spasmodic 
variety which he will have to deal with. 

The attack generally occurs suddenly and at night, the child waking 
with a hoarse, hard, clanging cough. His voice and cry may be hoarse, 
but not whispering. There is alarming dyspnoea from the beginning, 
and each inspiration is attended by a loud cooing or crowing sound. 
The attack, if left alone, may probably pass off in a few hours, and 
the child sleeps and awakes nearly well, though the attacks may, and 
probably will, return again upon subsequent nights. 

The physician will see that, called by whatever name, he has got to 
deal with a mild laryngitis, probably of catarrhal origin, accompanied 
by spasm of the laryngeal muscles, in which false membrane, diph- 
theria, or exudation plays no part. 

The treatment of this affection is simple. A smart emetic is indi- 
cated at the outset. The choice lies between ipecacuanha, tartar 
emetic, sulphate of zinc, sulphate of copper, apomorphine, squill, or 
mustard and hot water, with mechanical tickling of the fauces by a 
feather. 

Ipecacuanha — 5 grains, or drachm doses of the wine may be given 
every fifteen or thirty minutes to a child of two years old. §- grain 
of tartar emetic may be given in solution, or half drachm doses of the 
wine every fifteen minutes, till vomiting supervene. 

The following mixture is more valuable than either of its active 
ingredients when given alone. 
It may be given to a child one year old : 

R. — Yini antimonii ...... 5jiv (t. e., gr. j). 

Vini ipecacuanha? 3 iv. 

Syr. scillpe ....... ^iv. 

Aquae dest ad ^iij-— M. 

S. — A teaspoonful every fifteen minutes till vomiting occurs, then half a tea- 
spoonful every two or three hours while the cough lasts. 

Sulphate of zinc in 3 grain doses, or the copper salt in ^ to -J grain 
doses, acts more promptly, but the after nauseating, expectorant action 
of the ipecacuanha and antimony is most valuable, as the dry, swollen, 
or congested condition of the mucous membrane is relieved, and the 
secretion of mucus increased. 



croup. 157 

The writer has never given ape-morphine as an emetic to very young 
children, and from large experience of its use by the mouth in adults 
he would fear that its emetic action in infants would be uncertain, and 
followed by much depression. Unless in desperate emergencies it 
would appear that the hypodermic administration of it to very young 
children should not be resorted to. -fa to -^ grain probably would 
cause vomiting in a child one year old when given hypodermically. 

After the establishment of free emesis the symptoms of laryngeal 
spasm generally rapidly subside. It will be found wise to continue the 
use of expectorants for a few days longer, to keep the child well clad 
and confined to the sick room, the atmosphere of which should be warm 
and moist, and due precautions should be taken against future attacks, 
which are apt to be easily induced by even mild attacks of catarrh 
from exposure to cold and damp. 

While the action of the emetics is being established, the child may 
be plunged into a warm bath, and after being rubbed dry and placed 
between blankets a hot poultice may be tied round the throat, or 
Graves' method may be tried of applying a sponge squeezed out of 
very hot water, and kept in close contact with the laryngeal and 
tracheal region, and renewed every few minutes till thorough redden- 
ing of the skin be produced. Some cases where the symptoms are 
severe may require blisters, and a small cantharides blister, not larger 
than a florin, may be placed over the larynx and trachea for two hours, 
and be followed by a warm poultice. Stimulants may be given if the 
symptoms continue for any length of time, especially in weak children, 
and pulmonary complications, if present, must be treated by counter- 
irritation and ammonia with sustaining diet. 

About the nature of true croup very conflicting opinions exist, and 
from a study of the writings and experience of those who have had 
opportunities of dealing largely with the disease, it is impossible to 
come to any other conclusion, but that different writers have described 
two totally different affections under the name of true croup. Though 
this is not the place to dwell upon the pathology of the affection, a 
clear conception of the two prevailing opinions must be formed before 
the physician can reconcile the different reports of the treatment 
recommended by and adopted by those who have written upon the 
subject, but only the briefest reference can be made to these views. 

In France and Germany croup is regarded as true diphtheria mani- 
festing itself by the production of a membranous exudation in the 
larynx or trachea, or in both, this membrane being always the local 
manifestation of a general asthenic disease, and never the result of 
simple acute inflammatory action. 

By the majority of English authorities true croup is still regarded 
as a true or simple acute inflammation of the lining membrane of the 
larynx or trachea, or both, generally, though not always, eventuating 
in a membranous exudation. 

The physician who takes one or other side of this dispute will find 



158 croup. 

his treatment of the disease very much modified by the views which he 
holds, and it is manifest that there must of necessity be a wide differ- 
ence between the termination of a case of a highly infectious asthenic 
disease and a simple acute inflammation of the laryngeal mucous mem- 
brane. The writer has seen a few cases where all the clinical pheno- 
mena, mode of onset and termination, corresponded to a typical exam- 
ple of true croup as described by French and English writers, and he 
was satisfied that there w r ere features present which proved that these 
cases were true laryngotracheal diphtheria. He is, however, certain 
that the affection as ordinarily seen, and known by the name of " true 
croup " in the north of Ireland, and which presents the chief clinical 
features described by French and English physicians, is not diphtheria. 

For very many years, in the city of Belfast, diphtheria was practi- 
cally unknown, and one of the ablest and most learned physicians, in 
extensive practice, informed the writer in 1876 that, though looking 
out always for the disease, he had never once, seen a single case of the 
affection during twenty years. 

Cases of true croup were constantly to be met with during this 
period, and very often proved fatal, arid there clinical features were, 
apparently, the same then as to-day, when diphtheria is, by no means, 
so uncommonly seen in the locality, though the number of cases of 
true croup is certainly not on the increase. 

From many other considerations also, the writer believes that, in the 
great majority of instances, when the physician is called to treat a case 
of true croup in this country, he may safely feel that he is dealing with 
a non-contagious acute inflammation of the upper part of the air- 
passage, and may act accordingly. 

If the ease be seen at the very beginning of the attack (which is 
rare, as the symptoms of true croup are more insidious and less alarm- 
ing than in false croup), an emetic should be at once administered. 
The mechanical act of vomiting clears the air-passages of all secretion, 
and the after effects of the nauseating expectorant are most valu- 
able in modifying the nature of the inflammatory or congestive 
action, and liquefying the expectoration or thickened secretion of 
the parts. The physician must be guided in his choice of an emetic 
by the features of the individual case, and, as a rule, the remarks made 
upon this detail, when speaking of the treatment. of false croup, are 
also applicable here. Tartar emetic alone, or in combination with 
ipecacuanha, is the most reliable method of producing emesis at this 
stage. 

Much mischief may be done by pushing this remedy, though, in 
spurious croup, there is little danger of overdosing with emetics because 
the attack is a short one, and there is little to be feared by depressing 
or exhausting the patient's strength. 

With true croup the case is different. The siege is a much longer- 
one, and everything that draws upon the slender resources of the little 
patient must be avoided, and his strength jealously watched, no un- 



croup. 159 

necessary expenditure of force or energy being permitted. Hence, 
after an early emetic, farther administration should be suspended till 
there are signs of the formation of a membrane. Antimony, in large 
and repeated doses, is therefore contra-indicated. 

Having then decided upon an emetic and while awaiting its action, 
the physician proceeds to carry out the other important indications in 
the way of treatment. The patient is put to bed, and the temperature 
of the sick room raised to 60° or 65° F. by the combustion of coal in 
an open grate. The use of gas and other stoves is to be discoun- 
tenanced. Should the patient be a very young child or infant, or 
should it exhibit much restlessness, it will be found a wise course to 
undress it completely and put on a little flannel night-dress, and wrap 
it up in a warm blanket and place it upon the knee of a good nurse. 
The air of the room must, as far as possible, be saturated with steam 
or aqueous vapor. This is best done by the ordinary bronchitis kettle, 
or, in its absence, by fitting a tube of lead, tin, or even paper upon the 
pipe of an ordinary kettle, and leading the steam within safe distance 
of the patient's face. 

Where the child can be placed in its cot, and a canopy made by 
hanging sheets over and around it, a moist and warm atmosphere can 
be easily maintained for any length of time. Where this is not prac- 
ticable, the nurse and child may be surrounded by tall screens, inside 
which the tube from the kettle may be brought. The various inven- 
tions for boiling water and creating steam — by the combustion of gas, 
paraffin oil, and alcohol — in the sick room, should be avoided, as the 
air may be rendered dangerously impure in this way, and it should 
never be forgotten, as it too often is, that the purity of the air is of 
vital importance to the patient, who can only get a limited quantity 
into the lungs at each inspiration. 

The ventilation of the room is an important matter for this reason, 
and the physician should superintend these arrangements himself. It 
is a wise plan to strictly insist that as few persons as possible be allowed 
to remain in the sick chamber for any length of time, and the tempera- 
ture of the room should never be allowed to vary, if possible, more 
than a few degrees. A thermometer should be suspended somewhere 
in the immediate vicinity of the patient, and the nurse should see from 
time to time that it registers always about the same heat — i. e., about 
60° if in winter or 65° if in summer. 

The diet from the very first should be sustaining and stimulating. 
Milk in various forms, and peptonized if necessary, will be the most 
appropriate. Beef tea, beef jelly, Valentine's meat juice or chicken 
jelly should be given in small quantity and often, the physician remem- 
bering that soon a time may come when appetite and digestion will 
lag, and when it will be both difficult and injudicious to force the 
nourishment upon the little patient. 

A skilful nurse will know when to present it, and if emetics must be 
continually administered she will give aliment as soon as possible after 



160 CKOUP. 

the effort of vomiting has subsided, so that digestion may be as little 
interfered with as possible. As the child gets peevish it may refuse all 
food and ask for water ; if this be freely given and thirst assuaged, the 
child may very soon have no desire for anything else, and feeding be 
at a standstill. It will thus be wise to only give milk or liquid nour- 
ishment all through. Stimulants at a later stage may be indicated, 
and if so they should be freely given, and if possible always along 
with the food. Coleman's beef wine with extract of malt is very 
suitable, and generally is relished by children. Rennet may be added 
to the milk, or pepsin may be mixed with the beef tea; and later on, 
when swallowing becomes difficult owing to the dyspnoea, or when 
great nausea or vomiting prevents the food being got into the stomach, 
rectal feeding with peptonized food should be tried. For this purpose 
the valuable nutritive suppositories of Griffin are exceedingly conveni- 
ent. It may be advisable in some cases to stop all feeding by the 
mouth for a time, say eight or ten hours, and the nutritive supposito- 
ries if retained will well support life alone ; by this time the child may 
greedily take food. 

Before mentioning the different remedies generally given internally 
for the relief of croup, local treatment may be considered. Hot poul- 
tices to the throat and neck afford some ease, and may do good by 
relaxing spasm. Hot compresses, or a collar of spongio-piline squeezed 
out of hot water, is more convenient, and sometimes the appearance of 
a hot poultice sends the patient into a struggling fit, which always does 
harm. Cold compresses in some cases afford comfort, and if so they 
may be persisted in with advantage. They were much used by 
Memeyer. 

Cauterization of the larynx with nitrate of silver or other caustics 
should never be attempted ; and even in those rare cases where the 
disease is evidently depending upon diphtheria, and the membrane is 
visible in the pharynx, cauterization is a very questionable proceeding 
in the case of young children. 

Various substances in the form of vapor or spray have been locally 
applied. Of the vapors the following have been used, either sprinkled 
about the room, added to boiling water, or inserted on lint into the 
receptacle in the nozzle of the pipe of the bronchitis kettle : Eucalyptus 
oil, creasote, iodine, bromine, carbolic acid, tar, terebene, turpentine, 
tinct. benzoin, comp., chloroform, etc. 

It is very questionable if any good ever results from these vapors ; 
undoubtedly harm arises if the concentrated vapor of any of these 
substances reaches the larynx. A little turpentine or eucalyptus is of 
use by assisting to keep the air of the sick chamber sweet and pure. 
Oxygen inhalations may be useful in the later stages. 

Rothe recommends the vapor produced from heating a small quan- 
tity of calomel upon a plate under the bedclothes. 

Sprays have been much used in croup and also in diphtheria, and if 
judiciously employed much good may be achieved by them, those who 



CROUP. 161 

believe in the diphtheritic nature of croup place most faith in their 
use. 

Seigle's steam spray apparatus may be selected to diffuse a solution 
in the form of very fine spray against the fauces. The India-rubber 
apparatus used for scattering perfumes, and which may be obtained 
from any chemist, is much simpler and quite as good. The following 
is, perhaps, the best of local spray applications : 

R.— Pulv. sodii bor 3jss. 

Grlycermi . . . jfj. 

Aquae rosae ad 3 vii j . — M. 

S. — To be used every half hour as a spray. 

Various substances are employed in this way, with the view of 
causing solution or disintegration of the membranous exudation be- 
lieved to be present. Lime-water and lactic acid are the most fre- 
quently used ; 1 ounce of the dilute lactic acid (1:7) may be added to 
the above formula. The following is used on the Continent : 

R. — Acidi lactici 3 lij. 

Liquor calcis ^ Yn j- — M- 

S. — To be used as directed. 

Carbolic acid (1 drachm to 10 ounces) is also used, and sulphurous acid 
has been tried, but it might cause dangerous laryngeal irritation. Pure 
liquid vaseline spray is soothing, and can do no harm. Papain, pepsin, 
trypsin, and other substances, which have been used as direct applica- 
tions to diphtheritic patches in the pharynx and on the tonsils, have 
been recommended in croup, but their use has not been attended with 
any benefit. Of all the remedies employed locally, the weak spray of 
glycerin and borax, or carbolic acid, is the least objectionable and most 
likely to be followed by some benefit. 

Of remedies for internal use in the treatment of croup there is prac- 
tically no end. Many of these have been urged upon very slender 
theoretical grounds, and chiefly with the view of destroying germs or 
bacilli, which are supposed to be the sole cause of the disease. Only 
the most important will be mentioned. 

To return again to the management of the case. After the admin- 
istration of the first emetic, as mentioned on page 158, various methods 
of treatment may be selected by the physician. The writer, after try- 
ing many of these, is inclined to advise the use of a simple expectorant, 
which may be given every three or four hours without producing 
nausea or vomiting; and if symptoms of dyspnoea or embarrassed 
breathing appear, the same mixture may be given every ten or fifteen 
minutes till vomiting supervene. 

This treatment has the merit of doing no harm, and does not inter- 
fere with the more vital matters of food, stimulants, steaming, etc., 



162 croup. 

while many of the heroic methods advocated every year in the current 
literature of medicine must increase the mortality of the disease. A 
mixture like the following may be given to a child two years old : 

R 



-Vini ipecacuanhse . 


• • . . syi- 


Spt. setheris nitrosi . 


. 3iv 


Spt. ammonise aromat. 


. ^iij 


Syr. tolutani 


■ ■ • • • gj. 


Aquse camphorae 


ad j|iv. 



■M. 

S.— A teaspoonful in an equal quantity of water every two or three hours, 
and, if the breathing becomes distressing, every fifteen minutes till vomiting 
occurs. 

If feverishness be marked, i minim of tinct. aconiti may be added to 
the first six doses. Should the distress, cough, and dyspnoea demand 
the continuous use of emetics, one which will act quicker than the 
above is necessary. Tartar emetic is too depressing, and cannot be 
safely administered in the later stages of a disease characterized by 
great depression and muscular prostration. Apomorphine is open to 
the same objection. Alum in doses of half a teaspoonful with syrup 
every fifteen minutes is extolled as a safe emetic in croup. Sanguin- 
aria in powder is recommended highly in combination with ipecac. 

The writer has never seen it given in croup with this object, but from 
what he knows of the powerfully depressing action of the drug in other 
conditions, he does not intend to ever use it for this purpose. 

Turpeth mineral (subsulphate of mercury), in doses of 2 grains 
every twenty minutes, was used by the older practitioners with good 
results. 

Sulphate of copper, § grain in solution, given every ten minutes to 
a child one year old, was Trousseau's favorite remedy for producing 
vomiting in croup. It is not so safe as the sulphate of zinc, which 
may be given in doses of 3 grains, and repeated every ten minutes till 
vomiting results. 

Where ipecac is followed by too much depression, or where its action 
is too slow in the later stages of croup, the physician will be wise in 
discarding all emetics except the zinc sulphate. 

Oil of turpentine, in teaspoonful doses, has given very striking re- 
sults in the hands of Lewentaner. Calomel, in i to J grain doses every 
two hours, was given by Niemeyer, and some still follow his rather 
questionable practice. 

Corrosive sublimate, by way of variety, has been substituted for the 
calomel treatment, with the usual report, that it " has been followed by 
success," the dose for infants (one year old) being about -} grain, taken 
during the twenty-four hours. It has been combined with ichthyol 
inunctions and antipyrine enemata. 

The red iodide of mercury has been also given. Without further 



croup. 163 

knowledge of the action and effects of these heroic measures, the dis- 
crete practitioner will not be blamed for adhering to the old paths. 

Iodide of potassium, sulphide of calcium, tincture of iron, and every 
remedy used in diphtheria successfully have been administered with 
reputed advantages in croup. 

Jaborandi has been given with the idea of causing detachment of 
the false membrane, but the doses likely to have any effect in this 
direction would probably cause serious cardiac depression. The 
remedy, however, is certainly worth further trial, and some cases 
have been reported of very favorably since the drug was recommended 
by Sanne. 

Sooner or later, in the great majority of cases, the physician will 
have to face the question of tracheotomy. This is a very serious 
problem — one of the most serious in medicine, for various reasons, 
chiefly because if not done early it is almost certain to be useless. The 
physician hesitates to recommend the opening of the trachea or larynx 
in the absence of serious symptoms, and when the case presents no 
features contra-indicating recovery without the operation. Soon the 
aspect of the case deepens, he awakes to the probable necessity of the 
operation, mentions the subject to the patient's relatives — who always 
are stoutly opposed to the operation — delay occurs, and when the case 
becomes desperate, at last an operation is accepted, and by the time it 
is done death is sure to speedily follow it. 

The writer, who has opened the trachea several times under these 
circumstances, always felt that, as it was the only chance in desperate 
cases, it was criminal in parents to refuse consent, and imperative upon 
the physician to have the operation done even when the patient was 
sinking. 

All his cases, where he opened the trachea in children under five 
years of age suffering from croup in its last stages, died, and every 
case that he has seen operated upon by others has also died. During 
the last fifteen years he has not had personal knowledge of a single 
case recovering after the operation on young children who had been 
suffering from true croup. 

This melancholy record can only be explained by the hopeless stage 
at which the operation was undertaken. In none of the cases was 
there any difficulty in the operation save once, when the wound was 
blocked up in a diphtheritic patient, who was almost completely 
asphyxiated ; but the writer, after applying his lips directly to the 
wound, easily inserted the tube. This patient lived longer than any of 
the others, but died inside ten days, and though no ill effects followed 
the sucking of the wound, the writer would not do it again. 

This mortality of every case contrasts painfully with French statistics, 
and it is more than probable that the belief in the diphtherial nature 
of the disease in every case determines a very early operation. 

The writer's unfortunate experience, and his knowledge of the equally 
unfortunate experience of his friends, suggest to him that it may be 



164 ceo up. 

his duty to recommend non-interference when the case is in the last and 
hopeless stage. Though this is a very serious decision, he has taken 
the responsibility in two cases lately where an early operation was 
urged, but the parents refused their consent till congestion of the 
lungs, asphyxia, cold extremities, complete muscular prostration, and 
absence of pulse led him to advise that it was then too late for inter- 
ference. Any remnant of a shadow of hope seemed to him to be as 
great, if not greater, if the patient was left alone, death appearing to 
be certain from the operation. 

As soon as the thoracic walls begin to fall in during the act of in- 
spiration, an operation should be insisted upon ; but, if the parents 
refuse their consent, the advice should be repeated later on, and the 
surgeon, it is needless to say, should not refuse to open the windpipe as 
long as the faintest hope of success is likely to attend the operation. 

It may seem as if the writer has dwelt upon this aspect of the great 
mortality in late tracheotomy perhaps too much, but he believes that 
there is a serious danger of the physician himself being a party to the 
delay, and hence it is of vital importance that he should keep before 
him the view that, if he procrastinate^ there will certainly come a time 
when it will be too late to operate successfully. 

Every physician should have a clear idea of the steps of the opera- 
tion, because circumstances may so place him in a position where it 
will become his duty to operate and save life ; before a surgeon can be 
procured it may be too late. 

The first question is the one of anaesthesia. Speaking generally, 
chloroform should be administered, but in many of the cases of croup 
or diphtheria that conies under the surgeon, the disease has advanced 
so far that partial anaesthesia has already taken place, owing to the 
venous condition of the blood, and the operation may be immediately 
commenced without waiting for the action of an anaesthetic. 

Owing to the anatomical condition of the air-passages in young- 
children, the operation of laryngotomy should be left out of the ques- 
tion. The trachea should be opened, and the opening in the tube 
should always be made above the isthmus of the thyroid gland. Some- 
times the isthmus must be divided if the space is limited, but the 
operation in young children should never be attempted with a view to 
open the trachea and insert a tube below the isthmus. This is owing 
to the shortness of the neck in children. The operation for croup 
or laryngeal diphtheria in such cases is crico-tracheotomy or laryngo- 
tracheotomy. 

The patient should be placed in the recumbent position, with his 
thorax raised and the head extended. The operator, standing on his 
right, feels for the cricoid cartilage, and makes an incision having this 
point rather above its centre. The incision must be fair in the middle 
line, and may be made through all the soft parts in front of the 
trachea. About one and a half inches will be long enough. The 
trachea should be felt for by the tip of the left index finger, and any 



croup. 165 

veins drawn aside. When its rings come into view, the point of a 
sharp scalpel is inserted, and the first three rings, with the cricoid, 
should be divided from below upward. If the trachea does not promi- 
nently present in the wound, it may be caught up by a sharp hook 
and drawn forward, while the scalpel, with the edge upward, cuts an 
opening through the upper rings. After the air and mucus have 
bubbled into the wound and been expelled by the expiratory efforts, 
the tracheotomy tube can be inserted. The opening in the trachea 
must be free enough to take in as wide a tube as possible, and it is a 
mistake to make a very limited incision, as it greatly increases the dif- 
ficulty of inserting the tube. 

After the tube is placed in situ and fastened by broad tapes passed 
round the neck, the little patient is put into his cot, or allowed to sit 
upon the nurse's knee, the space around them being enclosed by 
sheets and canopied over, and the tube of the bronchitis kettle is 
brought inside the enclosure, thus ensuring a most, soft, and warm at- 
mosphere. 

The temperature of the room must be always watched by the ther- 
mometer, and never allowed to fall under 65° F. If the patient be 
old enough to be trusted not to pull at the tube, the ordinary " croup 
cot " saves much trouble, but if very young and restless, the nurse's 
knee is the safest place. It is absurd to attempt to keep some chil- 
dren by force in bed, and some will not tolerate the confined moist 
space. A large piece of muslin squeezed out of hot water may be 
folded and laid over the neck, covering the wound and tube in such 
cases. 

Nurse should be directed to constantly cleanse the opening in the 
tube, and if it gets plugged by mucus or shreds of membrane she may 
occasionally insert a feather previously dipped in any weak disinfec- 
tant, and fish about for any obstruction, which is easily entangled, in 
its plumules. The spray of glycerin and borax, or of weak carbolic 
lotion, may be constantly used, and will be of great use in keeping the 
skin wound healthy and sweet. 

The tube may be finally removed about the sixth day in most cases. 

After the operation the treatment must be scrupulously continued 
as before, food, stimulants, and a 'mild expectorant given regularly. 
Iron may now be ordered with great advantage. For a child two 
years old the following may be employed : 

R. — Tinct. ferri chlor 3Jss. 

Vini ipecac ^ij. 

Potassii chlor 3j. 

Glycerini et aquse ad ^ij. — M. 

S. — Take a teaspoonful in two teaspoonfuls of water every four hours. 

Some good results are published from the operation of intubation, 
and as improvements in the tubes are being steadily achieved, this 
method may yet become a most valuable one. 



166 DANDEUFF — DEBILITY. 

CYSTITIS— See Bladder, Inflammation of. 

DANDRUFF (Seborrhoea Capitis). 

The skin of the scalp should be saturated with oil, and kept in this 
state, no soap or washing with water being allowed. For cleansing 
purposes more oil should be poured on, and the scalp then rubbed 
clean with a soft cloth. Almond or olive oils are generally used, 
though inferior to an animal oil. It is difficult to get a suitable animal 
oil free from odor. Lard is too thick. Trotter oil is the best, but 
there is difficulty in procuring it genuine. Merely smearing of it over 
the hair is useless ; it must be applied freely to the scalp! 

In mild cases the oil treatment is all that is required, but if the case 
resist this method, the scalp must be submitted to thorough cleansing 
at intervals of not more than seven days. 

This may be done by using powdered borax as a soap. With tepid 
water a good lather is easily raised, and the scales are dissolved or dis- 
integrated, and the scalp thoroughly cleansed. After drying, the oil 
is applied again. 

Yolk of egg may be used in the same way. Hebra used a saturated 
solution of green soap in alcohol for this purpose. 

Shoemaker recommends the oil of ergot, and uses soda soap, medi- 
cated with oil of chamomile and sulphur, to wash off the scales. 

A weak ointment of the oleate, or of the red oxide of mercury, or 
dilute citrine ointment, is sometimes useful. Some specialists, believ- 
ing in the parasitic origin of the disease, advise weak solutions of cor- 
rosive sublimate, lotions of sulphur, and long lists of antiparasitic sub- 
stances. 

Internal medicines appear to be useless. 

The partial baldness often resulting is best treated by the ointments 
mentioned under baldness. 

If chronic eczema has been the cause of the seborrhoea, the follow- 
ing often rapidly causes permanent improvement : 

R. — Liq. carbonis detergens . . . . . sjij. 

Hydrarg. ammon 3j. 

Vaselini ^iij. — M. 

DEBILITY. 

The treatment of this condition need not be dwelt upon here. The 
indications are those for the treatment of the different diseases of 
which the debility is the result, and the remedies will be given under 
their appropriate headings. 

Measures which improve nutrition, as cod-liver oil, iron, alcohol, 
massage, arsenic, phosphates, malt extracts, quinine, bitter tonics, gal- 
vanism, static electricity, sea voyages and bathing, exercises of various 
kinds, and the remedies suitable for the different forms of debility, 



DELIRIUM — DELIRIUM TREMENS. 167 

whether caused by constitutional diseases like fevers, phthisis, etc., or 
produced by disease in separate organs, as in valvular heart affections, 
will be mentioned when the treatment of these diseased conditions are 
discussed. 

DELIRIUM. 

The appropriate treatment of this symptom will be referred to when 
considering the treatment of the different fevers and diseases upon 
whose presence the delirium depends. (See particularly under Typhoid 
Fever.) 

DELIRIUM TREMENS. 

About the treatment of this serious affection much difference of 
opinion has always existed, but the difficulty is certainly becoming 
less since the natural course of the disease, when left to itself, is becom- 
ing better understood. The patient, even in the mildest case, should 
be regarded as insane for the time, and it is the serious duty of the 
physician to impress upon his friends that he cannot be trusted for a 
moment out of sight, as the delusions or illusions under which he suf- 
fers may impel him to injure himself or others. Often his surround- 
ings are such that removal to a properly regulated hospital, where 
suitable provision for such cases is provided, is the only course open to 
the physician to recommend in violent cases. The room in which the 
patient is to be confined while the active stage lasts should be as free 
from noise and disturbance as possible, and attention should be given 
to the window fastenings and all removable furniture, and objects 
which might become formidable weapons in the hands of a delirious 
patient should be placed outside his reach. Though the great majority 
of the subjects of an attack of delirium tremens betray no evidence 
of suicidal or homicidal tendencies, the writer has encountered many 
instances of the contrary during a prolonged residence in hospital, 
where such cases were common. He has witnessed and experienced 
several hair-bredth escapes from their violence, while they were labor- 
ing under the delusion that the nurse or attendants were the hated 
objects which the hallucination of their disordered vision had con- 
jured up. The room should be kept in comparative darkness, and it 
will be well if the patient can be kept in bed. Much will depend 
upon the tact of the nurse, who may be able by humoring the patient 
to keep him quiet and at rest. Violent and repeated struggles may 
be caused by an indiscreet and quick-tempered nurse, and may have a 
serious influence upon the patient's chances of recovery in bad cases. 
As a rule, forcible restraint will not be often called for, and the nurse 
should be made to understand that it is much easier to keep a patient 
upon his back in bed by gentle persuasion and mild restraint than to 
allow him to once get up and initiate a struggle, when considerable 
force will be necessary to get him again into bed. Where this method 



168 DELIRIUM TREMENS. 

fails with a restless patient a sheet may be so tied across the bed or 
tucked in that his movements will be considerably hampered. The 
straight-jacket — rightly regarded by every physician with disfavor — 
must in some cases be employed ; and the writer has satisfied himself 
that he has seen it induce rest and calm, without which the patient's 
struggles could not have been subdued, and death from exhaustion 
would inevitably have supervened. Such cases are, however, rare, 
and are no justification for the coarse or cruel abuse which sometimes 
may be noticed at the hands of untrained nurses or attendants. 

The physician should insist that, save one relative or friend who 
may have the right of passing in or out of the sick-room, all visitors 
must be strictly forbidden, and the most complete rest and quiet made 
to prevail. 

Food should be administered with regularity, and it should be of 
the most sustaining and stimulating kind. Solid food, owing to the 
state of the digestive organs, cannot be taken. Strong soups, beef tea, 
beef essences, and beef jellies, with an unlimited supply of milk, should 
form the diet of a patient during the acute stage of the disease. 

Attention to these measures will safely carry a large majority of 
patients through their attack, and without any narcotics or hypnotics, 
upon the third night or fourth morning the patient exhausted and 
wearied by his restless movements, falls into a natural slumber of 
variable duration, from which he generally awakes comparatively well 
and free from hallucinations. 

To properly treat the disease in all cases, the physician must keep 
this spontaneous tendency toward recovery always before his mind. 
Many cases, nevertheless, will demand some further therapeutic meas- 
ures, and few instances will occur in which some of the distressing 
symptoms may not be removed or modified by judicious administra- 
tion of medicine. 

The first question which the physician must decide is the one of 
alcoholic stimulants, and, as mentioned under alcoholism, the popular 
prejudice is strongly against the withdrawal of the patient's favorite 
beverage. In many instances it will be found that he has already 
ceased drinking just before or soon after the first symptoms of the affec- 
tion have declared themselves. The physician may be certain that in 
the great bulk of cases alcohol will do no good, and in very many, 
especially in young subjects in their first attack, its administration 
will aggravate or prolong the excitement. 

The case is different with older patients, especially those who have 
taken alcohol for long periods, and in whom symptoms of pneumonia 
or of cardiac failure manifest themselves. Here alcohol must not be 
withheld unless at great risk ; but such cases are comparatively rare, 
and even in them the alcohol should not be started at the very begin- 
ning of the attack. When dyspnoea, pallor of the face, or lividi^y, or 
any approach to symptoms of syncope, with failure of pulse, alcohol 



DELIRIUM TREMENS. 169 

must be given freely, in conjunction with large doses (1 drachm) of 
spt. ammon. aromat., or ether. 

The great question in the treatment of delirium tremens is the use 
of narcotics or hypnotics. There cannot be a doubt but that some 
cases would be better without them all through the attack, and it is 
equally certain that they should not be given in any case at the begin- 
ning. It appears probable that a patient who would not fall into 
natural sleep till about the fourth night if let alone, will not be sent to 
sleep by narcotics much sooner. It is also highly probable, where sleep 
has followed the use of a narcotic in the early stage, that the case has 
chanced to be one of those mild forms of the affection which would 
have terminated in sleep if left to itself. Should hypnotics, then, be 
administered at all in delirium tremens? The answer to this question 
must be in the affirmative. 

The writer has satisfied himself that even a very short curtailment 
of the period of excitement in bad cases may save life, and one cannot 
help reflecting, after witnessing the death of a patient, say upon the 
fourth day of a restless and exhausting delirium, that had sleep 
been induced by any means, even by chloroform, a short time before 
the fatal termination was due, a different result might have been 
obtained. Had the patient lived for another hour, possibly sleep 
might naturally have occurred, and the question in such terribly 
serious cases is, can sleep be artificially induced at even a brief period 
before it naturally might fall due? This seems so highly probable 
that one must be undertaking a very serious responsibility who would 
withhold all narcotics or hypnotics from a patient sinking from the 
exhaustion caused by a restless delirium and want of sleep. 

At the same time it must be remembered that many deaths have 
been attributed to the free use of the narcotic, and that Wilks stated 
he had seen many cases of delirium tremens sent to their last sleep by 
opium. 

The physician thus finds himself placed in a grave difficulty, when 
dose after dose of narcotic fails to induce sleep in a patient apparently 
sinking from the exhaustion which sleep would soon banish. 

The difficulty is made no less by the knowledge that owing to the 
state of the digestion and absorption these doses may lie in the stomach 
or intestines unabsorbed for a time, and then may all rapidly enter the 
circulation at once. 

Consideration of this last possibility should discountenance the 
administration of solid opium in delirium tremens. 

Another plea for the use of narcotics in this affection might be made 
out by stating what the writer believes to be the fact in some cases, 
that when sleep does occur it is sounder and more lasting, and hastens 
the recovery of the patient. 

If the judgment of the physician leads him to believe that a mode- 
rate hypnotic will be beneficial in a given case, he should not think of 

12 



170 DELIRIUM TREMENS. 

giving it sooner than twenty-four or thirty hours after the onset of the 
symptoms. 

Early restlessness and activity may be benefitted by full doses of 
bromides, and some advantage may be constantly observed where 
sleep has not supervened. The bromide of potassium in 30 grain 
doses, often calms perceptibly the excitement of young subjects. 

Of all the hypnotics used none is so dangerous as chloral, though 
this was the drug considered by Anstie to have the power of cutting 
short the disease, and the drug for which he thought there was a 
marked tolerance in delirium tremens. The writer has seen it tell 
with fatal rapidity upon the heart in the disease under consideration, 
and he has long since ceased to prescribe it. 

40 minims of laudanum or liquor morphine (1 : 100) may be given 
about the sleeping hour of the patient upon the second night of his 
attack, and if sleep does not follow it should not be repeated till the 
early hours of the morning, and not again until bedtime the following 
night. Should the state of affairs be the same upon this night as upon 
the second, one dose of 30 minims may be given early upon the fourth 
morning. If sleep does not supervene by the fourth night (say seventy- 
two hours after the onset of the disease), the situation will become 
serious, and the full dose may be again repeated, to be followed by 20 
to 30 minims every four hours until sleep comes on. Should excitement 
follow each repetition of the opiate, its administration should be sus- 
pended and it has been long observed that rapid improvement often 
follows one or two doses of tartarized antimony (i to I grain). 

It is advisable ,to clear the bowels out by a smart purge before 
beginning the opiate treatment, and if the physician suspects that the 
remedy is not being absorbed, he may give a corresponding amount by 
the hypodermic needle when the next dose falls due in four hours. 

Paraldehyde in 60 minim doses, and sulphonal in 40 grain doses, 
have been used to great advantage, and many physicians of late years 
are content to treat all cases with one or other of these drugs. They 
are, moreover, perfectly safe in the above-mentioned doses. 

Hyoscine hypodermically (y^-g- grain) has been tried as a hypnotic, 
and has given splendid results in delirium tremens. Merck's prepara- 
tion only should be used. 

Digitalis, in very large doses, has been freely given, and it is rather 
surprising to find that a heavier mortality has not been reported after 
doses of 240 minims of the tincture every four hours. These heroic 
doses have, unfortunately, been followed by some dangerous symptoms 
which may have the effect of preventing the administration of the drug 
in delirium tremens. It is, in reasonable doses, a most valuable remedy 
where there are signs of cardiac failure, but to be of use it must be 
given early, as the slowness of its action, which is often overlooked by 
physicians, renders it of little use in sudden failure of the cardiac 
muscle. 

Strychnine acts much more quickly, and has an antagonistic action 



DEMENTIA. 171 

to alcohol. (See under Alcoholism.) The tincture of mix vomica 
may be given in doses of 15 minims every four hours with 7 minims of 
tincture of digitalis, and, where cardiac failure threatens seriously to 
cut off the patient, in addition to the free use of whiskey with ammonia, 
as already mentioned, it is a good practice to give a large hypodermic 
dose of strychnine; y 1 ^ grain will be enough, and may be repeated in 
three hours. Hot mustard poultices to the cardiac region and spine 
should be used at the same time. 

Capsicum, in 20 grain doses, has been strongly recommended to pro- 
duce sleep, but the writer has been disappointed in the results obtained 
by it in hospital practice, and, if there be any chance of acute gastritis 
supervening upon the debauch w T hich led to the attack of delirium, it 
might possibly do serious harm by adding fuel to the fire. Never- 
theless, good results have been reported in the hands of reliable 
authorities. 

Belladonna, hyoscyamus, arnica, sumbul, lupulin, stramonium, and 
many other remedies of the same class, have been used with varying 
success. 

Albuminuria may indicate kidney lesion, which seriously complicates 
the attack, and urseinie convulsions may occur. They should not be 
mistaken for epileptic seizures, which also often occur. A convulsion 
coming on, accompanied by a large amount of albumin in the urine, 
should be promptly treated by saline purgatives and a hot mustard 
pack. (See Bright's Disease.) 

Complications, as they arise, must be treated upon the general prin- 
ciples mentioned under the head of each. As a rule, they are an indi- 
cation for stimulants. Pneumonia is especially serious. 

Delirium tremens, the result of an injury or accident in intemperate 
and irregular living subjects, is very common in the surgical wards, 
and generally turns out a grave affection. It may come on with 
alarming rapidity, and it is the writer's experience that the delirium 
in these cases is often of a more active and dangerous kind, and free 
stimulation is much more frequently indicated in this group of cases 
than in the ordinary medical varieties of the disorder. 

DEMENTIA. 

In the acute variety of this affection much can be done by judicious 
treatment. The essence of all treatment lies in forced feeding, and if 
carried out systematically and persisted in, even when the case appears 
hopeless, great improvement and even permanent cure often results. 
The food should be given in the liquid form, and, practically, in 
unlimited amount. By the India-rubber tube of the stomach pump 
6 to 8 pints of peptonized milk may be put into the stomach daily. 
This may be prepared by using Fairchild's peptonizing powders, or by 
dissolving 5 grains of pancreatin with 20 grains of sodse bicarb, in 1 
ounce of water, and adding the solution to 1 pint of milk, which should 



172 DENGUE. 

be kept for one hour at 110° F. Gruel may be peptonized in the same 
way by adding the same solution and digesting for one and a half 
hours, after which it should have a rapid boil. Beef tea may be more 
successfully treated by adding liquor pancreaticus (i ounce to a pint), 
after having previously added the soda, and then the compound 
should be digested at about 100° for a couple of hours, and used 
immediately. 

Rectal feeding may be necessary in extreme cases. 

There is, however, no remedy like massage, but this should only be 
attempted when the forced feeding is being freely carried out. 

Malt extracts, cod-liver oil, iron, quinine, or bark, with dilute nitro- 
hydrochloric acid, alternating with small doses of arsenic, may be given 
with great advantage. 

Stimulants should, as a rule, be freely given at first till the activity 
of the alimentary canal and the nervous system be roused from its 
torpor by the increased nutrition. 

The constant current, twenty Leclanche cells, may be applied to 
different parts of the body for a period of fifteen minutes twice daily, 
and static electricity has a powerful influence over the general nutri- 
tion. 

The patient's body should be enveloped in thick flannels, and arti- 
ficial warmth is almost always required. 

Where the dementia is secondary to some brain disease or functional 
disorder, the treatment of the original affection is indicated. 

DENGUE. 

A smart purge should be administered at the beginning of the attack, 
but the older methods of treating this specific fever by constant pur- 
gation is now abandoned. One good dose of calomel generally will be 
found sufficient. 

Quinine in 5-grain doses may be maintained as long as the tempera- 
ture keeps high, and it probably may be found that the new anti- 
pyretics will be of value, especially as the initial fever is short and 
sharp. Sometimes . the cold pack, or douche, or sponging must be 
resorted to when 105° F. is reached. Lately, salicylate of soda has 
given good results. 

Belladonna has been found of great use for the relief of the joint 
pains, and may be combined with opium, thus : 10 minims each of 
laudanum and tincture of belladonna may be given every two or 
three hours for four or five doses with marked benefit. After the 
subsidence of the acute symptoms, bromides and iodides are valuable, 
though generally anti-rheumatic remedies afford little relief to the 
arthritic complications. The convalescent stage may be managed 
upon the general principles indicated in the treatment of our own 
specific fevers. 



DENTITION, DISORDERS OF. 173 

DENTITION, Disorders of. 

A great deal of importance has been attached to the conditions often 
found associated with or attributed to the eruption of the milk teeth, 
and various disorders having nothing whatever to say to dentition 
are being constantly brought before the physician as cases of delayed 
or irregular teething. Nevertheless, it is a daily matter of obser- 
vation that certain symptoms appearing at this period demand prompt 
treatment. 

Convulsions may be fairly traced to this source, and under that 
heading the indiscriminate scarification of the gums has been dwelt 
upon, and the evils resulting therefrom mentioned. (See Convulsions, 
page 149). 

The chief indications for the treatment of the various combinations 
of symptoms noticed at this period in young children may be easily 
decided by a study of the mechanism causing these disturbances. The 
very marked impressibility of the different nerve centres in the young 
child, owing to developmental causes, renders any peripheral irritation 
liable to be followed by phenomena more or less general. This impres- 
sibility of the nervous system may be controlled or altered by drugs, 
and there* are few conditions in which more immediate and striking 
relief may be harmlessly obtained. Opiates should not be employed ; 
the relief they afford is dearly purchased, as they leave the nerve 
centres still more susceptible to impressions which in the normal con- 
dition give rise to no reflex manifestations. 

Bromides are invaluable, and no harm can follow the administration 
of full doses of the potassium or ammonium salt. In some way, not 
so easily understood, the domestic remedy — nitrous ether — has a de- 
cidedly beneficial effect. The writer guesses that its soothing influence 
depends upon its power of causing dilatation of the small vessels; Pro- 
fessor Leech has shown that in full doses it reduces arterial spasm in 
angina pectoris. It appears to do good also in causing the skin to act, 
and thus relieves the irregular fever so constantly found associated 
with symptoms depending upon delayed dentition. Peevishness, 
restlessness, wakefulness, muscular twitchings, night terrors, vomit- 
ing, diarrhoea, and the characteristic series of teething troubles often 
rapidly yield in an infant of about twelve months old to the following 
simple combination : 



& . — Ammon. bromidi . 

Spt. setheris nitrosi 

Liq. ammon. acet. . 

Syr. simplicis 

Aqupe cinnamoni . 
— Take a teaspoonful every two hours. 



. gr. xxx. 
. 3iv. 
ad gij. — M. 



The bowels should be cleared out by a teaspoonful of castor oil, pre- 
ceded by a dose of 1. grain of gray powder. It is a good plan to give 



174 DIABETES INSIPIDUS. 

the mercurial in a teaspoonful of syrup of senna, and to omit the oil. 
The senna can be repeated without the gray powder ever four hours 
till the bowels act. It is easily taken by all children. 

DIABETES INSIPIDUS: 

The treatment of this affection is very unsatisfactory, and though 
many drugs have been used, and successes unquestionably recorded, 
nevertheless the drug which benefits one case will have no effect what- 
ever upon the case next presenting itself, and we have no real knowledge 
of the pathology of the affection. Hence the treatment here mentioned 
can only be a brief list of the drugs or remedies which have been given 
with very decided benefit in some cases. 

The continuous current has been used in different ways. A strong 
current is employed, and the best method appears to be by placing 
the positive pole on the nape of the neck, and the negative over the 
loins and pit of the stomach, alternately, for four or five minutes at a 
time. 

Some physicians have contented themselves with a weak current, 
and have passed it through the base of the brain. 

Seidel found very marked improvement by placing one pole over the 
loin behind, and the other deeply pressed into the corresponding hypo- 
chondrium, galvanizing each side daily for five minutes. In some six 
or eight weeks of this treatment the urine was found to have fallen in 
daily amount from about ten pints to a little over three pints, the 
weight of the body rising by nine pounds. The amendment, accord- 
ing to Roberts's report, had been maintained at the end of three months. 
In many cases this treatment has signally failed. 

Antipyrine has been reported as markedly successful in several 
cases recently in the hands of Opitz. The daily dose should begin 
with 30 grains, steadily increased till 90 grains are reached. 

Trousseau's great remedy was valerian in enormous doses. He ad- 
ministered a drachm of the extract three times a day, and in one case 
he gave one ounce daily. 

Roberts had seen great benefit from the valerianate of zinc in one 
case of a boy, in which he saw the daily quantity of urine fall from fif- 
teen to five pints after doses pushed to the extent of 20 grains daily. 
Dr. Lindsay has reported successes after the administration of the ex- 
tract of valerian. Murrell found a case following a fall upon the head 
to yield to a course of belladonna and ergot. 

Nitrate of potash has proved very valuable in several cases when 
given in half-drachm doses. 

Iodide of potassium and iodide of mercury have been tried with suc- 
cess in a few cases. 

Bromide of potassium was tried by the writer in a case with striking- 
benefit, but the condition had lasted such a short time that there would 
be grounds for doubting that it was one of diabetes insipidus. 

Roberts, noticing how often the disease was relieved by the presence 



DIABETES. 175 

of some intercurrent inflammatory affection, was led to apply a large 
blister to the pit of the stomach with some benefit. 

Dilute nitro-hydrochloric acid, in drachm doses, has been reported 
to have cured several cases. 

Opium, morphine, codeine, and other narcotics do harm. Iron, 
strychnine, chloride of gold, gallic acid, ergot, creasote, alum, bella- 
donna, muscarine, pilocarpine, cream of tartar, and many other drugs 
have been used with very variable success. Some cases are upon 
record where, after failure of all drugs tried, rapid improvement has 
followed a change of air to the seaside. 

Warm clothing should be insisted upon, and the general health 
carefully looked after, signs of emaciation being treated by cod-liver 
oil, and the usual remedies applicable in the treatment of wasting 
diseases. 

A diet of dry or solid food with little liquids always causes rapid 
diminution in the amount of water passed, but produces such intense 
discomfort and depression that, as a method of treatment, it has' to be 
soon abandoned in each case. 

DIABETES. 

The most important portion of the treatment must be a well-regu- 
lated diet. If this be not most rigorously attended to, drugs will avail 
little. The physician will always keep before him the main object of 
furnishing for the patient a dietary as far as possible containing the 
least amount of sugar or starch, or substances easily convertible into 
sugar. But no two cases of the disease will thrive best upon an exactly 
similar diet table, and in this Comes in the secret of treating the affec- 
tion successfully. By daily estimation of the amount of sugar voided 
in the urine, and by weighing the patient at short intervals, the diet 
may be adjusted from time to time, so as to make life comfortable, and 
in many cases lead to a complete and permanent cure. The amount 
of sugar excreted will often convince the physician that some articles 
can be taken with safety and benefit by one patient which may seriously 
increase the disease in another. 

The best method for practical purposes of estimating the daily excre- 
tion of sugar is the one introduced by Sir William Roberts. It can 
be carried out by any intelligent patient (whenever it is wise to trust a 
patient with the details of his own ailment). 

The following are Sir W. Roberts's own words : 

"About 4 ounces of the saccharine urine are put into a 12 ounce 
bottle, and about the size of a small walnut of German yeast is added 
to it. The bottle is then covered with a nicked cork (which permits 
the escape of carbonic acid), and set aside on the mantel-piece or other 
warm place to ferment. Beside it is placed a tightly corked four-ounce 
phial filled with the same urine without any yeast. In about twenty- 
four hours the fermentation will have ceased, and the scum cleared off 



176 DIABETES. 

or subsided. The fermented urine is then decanted into a urine-glass 
and its specific gravity taken. At the same time the density of the un- 
fermented urine in the companion phial is observed, and the " density 
lost" ascertained. Fermentation is generally complete in about eigh- 
teen hours, if the locality be sufficiently warm ; and it is desirable to 
remove the two phials into a cool place two or three hours before the 
densities are taken, in order that they may attain the temperature of 
the surrounding atmosphere." 

The difference between the two densities — i. e., the density before and 
after fermentation — will give the number of grains of sugar in each 
fluidounce of the urine. Thus, suppose that the unfermented sample by 
the ordinary urinometer registers sp. gr. 1050, and that the fermented 
sample registers sp. gr. 1020, the urine for all practical purposes may 
be regarded as containing thirty grains of sugar per fluidounce. 

By multiplying the total number of ounces passed during the twenty- 
four hours by thirty, the total amount of sugar in grains will be easily 
obtained. Thus the physician will have an easy and accurate method, 
by means of which he can determine the result of dietetic and medi- 
cinal treatment, without which he would have to grope his way in the 
dark a great deal. 

In selecting a diet, the following must be avoided : Most vegetables 
(exceptions will be afterward enumerated), especially potatoes, turnips, 
cauliflower, carrots, peas, beans, parsnips, sea kale. 

Fruits — especially all sweet fruits — apples, oranges, pears, goose- 
berries, currants, plums, and peaches, must be forbidden. 

Farinaceous food must be strictly avoided, thus, corn-flour, bread, 
rice, sago, macaroni and vermicelli, tapioca, sweets, pastry, puddings, etc. 

Of the articles allowable, nearly every animal substance may be 
freely partaken of — any kind of meat, game, fish, or poultry; indeed, 
the only animal products which are injurious and must be avoided are 
liver, molluscs, and honey. 

In the cooking of animal substances, strict attention must be paid to 
the avoidance of adding any starchy or saccharine flavoring ingredients 
to the meat. Green vegetables, cabbage (when quite green), lettuce, 
cress, spinach, water-cress, celery tops, endive, young Brussels' sprouts, 
spring onions, French beans (when quite young), and green artichokes 
may be allowed in moderate quantities. 

Cheese, cream, butter, and eggs may be used in fair quantities. The 
question of milk will be considered afterward. 

There is, after all, but one difficulty in the treatment of diabetes by 
diet, and that is the question of bread. To provide a substitute for it 
which will contain neither starch, sugar, nor anything easily changed 
into sugar, and which will, at the same time, be both palatable and 
capable of sustaining life, is the great desideratum. 

Bran made into cakes by Camplin's method, with eggs, butter, and 
a little milk, are used, 



DIABETES. 177 

Gluten bread, made from carefully washed gluten, in which as little 
starch as possible is left, is, if made carefully, a palatable substitute. 

The writer has had much satisfaction from the use of gluten buns. 

Dr. O'Donnel gives the following formula for diabetic bread : Beat 
six eggs with a teaspoonful of baking-powder, add a quarter of a tea- 
spoonful of salt, beat again, pour into hot waffle-irons smeared with 
butter, and bake in a very hot oven. 

The following is Woltering's recipe for gluten bread : 

The bread is, he says, most conveniently and easily made with baking- 
powder. Mix one and a half heaped tablespoonful of baking-powder 
with one pound two ounces of gluten meal, and rub the mixture through 
a sieve ; rub up well in a bowl till thoroughly mixed, and work into a 
dough with half a pint of lukewarm water. It is now ready to be put 
in baking-tins and baked in a hot oven. It may also be made with 
yeast. Mix the same quantity of gluten meal with one halfpennyworth 
of "German" yeast dissolved in a few tablespoonfuls of warm water, 
and work into a dough with a quarter of a litre of lukewarm water. 
Put the dough, which is as sticky as glue, in warmed and buttered 
baking-tins ; it will rise in from one and a half to two hours. Bake 
for from one and a half to three hours in a hot oven ; turn every hour. 
The bread ought to have a hard, brittle, brown crust and a light-gray 
crumb. Like all gluten bread, it has a sour taste, which is not altered 
by the addition of egg, milk, butter, or bicarbonate of soda to the 
dough. Saccharin gives at unpleasant, sweet taste. Cream corrects it 
better than anything else; but it is not noticed if the bread is buttered 
and eaten with some savory, such as a sardine. After one or two days 
the bread remaining grows tough ; and should be toasted or cut into 
fingers and baked in the oven until brittle. This toasted bread is 
palatable with butter, or may be crushed and used for making pud- 
dings. The bread made with yeast contains 53.9 per cent, albuminoids, 
0.2 per cent, fat, and 2.6 per cent, carbohydrates. 

The writer has had several poor diabetics kept alive upon home- 
make bread, prepared by themselves from the crude gluten obtained 
from the starch works. This compound is far from being a proper 
diabetic food, but, among the poor diabetics discharged from hospital 
as incurables, it is the best that can be done for them. He directs 
them to take four breakfast-cupfuls of the finest bran, and a small tea- 
cupful of the best white Indian flour or meal, and rub these with six 
ounces of butter and a teaspoonful of bicarbonate of soda. This mass 
is then made into dough with the thick part of the washed gluten, 
which has been left to settle in a pail of water over night. The mass 
is to be rolled into cakes, and baked in a slow oven for two hours. 

Pavy believes that there is no article of food better suited to the dia- 
betic than the almond. Its highly nitrogenous and rich oily materials 
supply him with every want, and from it bread, buns, and cakes can 
be easily made, which are very palatable substitutes for bread. 

Purdy also speaks strongly of the almond flour, and shows that it 



178 DIABETES. 

should be prepared fresh, because of its speedy deterioration, owing to 
the 50 per cent, of oil contained in it. Rubbed up with eggs and well 
beaten and a little baking-powder added, it may be baked in small tins 
in any good oven without difficulty. 

The objection to gluten is that it always contains more or less starch ; 
to bran, that beyond the carbohydrates there is little else in it to 
nourish ; to the almond bread, there is no objection save that of ex- 
pense. 

Soya bread has come into repute. It is made from the grain of a 
leguminous Eastern plant which has been successfully cultivated in 
Austria. Like the almond, it contains much fat, and there is but a 
trace of starch found in it. It makes a bread not unlike rye bread, of 
which diabetics do not soon tire. 

Danype's bread is made with flour obtained from the embryo of 
wheat, after the separation of its starchy endosperm. It is being used 
in France for diabetics, and it is free from starch save in the merest 
traces. 

Fiirbinger's gum bread is much used in Germany. It is made by 
Basserman, of Manheim. 

Tea, coffee, and cocoa made from nibs, may be freely partaken of, 
sweetened with saccharin or glycerin, and containing good cream. 
There is little use in trying to diminish the amount of fluid consumed, 
and thirst may be assuaged by acidulated drinks made with cream of 
tartar, phosphoric acid, or lactic acid. 

Stimulants should be most sparingly used, and, when given, should 
consist of whiskey, or a little dry sherry, or very bitter ale. Sweet 
wines are decidedly injurious. 

The patient's hours should be very regular, and he should, as far as 
possible, be saved from bodily fatigue, worry, or heavy brain- work. 
Against changes of temperature he should be provided, by being well 
clad in flannel, and should wear thick-soled boots. Gymnastic exer- 
cises may be advised, when weather and other contra-indications forbid 
exposure. 

Before passing to the treatment by drugs, mention may be made of 
Donkin's method of treating diabetes by an exclusive diet of skimmed 
milk. About one gallon or more is the daily allowance. This treat- 
ment has met with pretty general condemnation, and most of the recent 
writers seem puzzled to account for Donkin's results. Notwithstand- 
ing these adverse opinions, there will be met with classes of cases where 
really no other dietetic treatment is available. The writer has seen, 
in at least three cases, the most decided benefits follow this method. 
In one (a fat patient) the sugar disappeared entirely, returned after 
the milk was stopped, and disappeared as long as it was adhered to. 
In poor patients who turn up at hospital, and who may gain admission 
for a few weeks or even months, when they are compelled to leave 
and return to their homes, milk is really about the only available safe 
diet for them. Severe cases of diabetes will, unfortunately, be often 



DIABETES. 179 

found where milk acts most injuriously ; but fat patients sometimes do 
well upon it. 

In agricultural districts buttermilk turned acid is a very valuable 
diet for the poor diabetic. In such cases bread, when stale, may be 
cut into very thin slices and toasted before the fire until browned or 
partially charred through, when it may be found that much of the 
starch is destroyed, and, when well coated with butter, can be eaten 
with comparative safety. 

Too much cannot be expected from a pure dietetic treatment of the 
disease, and though, now and then, the physician may meet with a 
case where the sugar disappears entirely ; nevertheless, in young sub- 
jects especially, the sugar can sometimes be very little influenced by 
diet. 

In every case there are various drugs which may be employed with 
more or less benefit, though the drug which is to exert a specific action 
in diabetes has yet to be discovered. 

Opium comes foremost amongst these. It can be tolerated in very 
large doses. The watery extract, in doses of ^ grain, three times a 
day, may be started with, and the dose need not generally be pushed 
beyond 3 or -1 grains. 

Morphine may be employed in proportionately smaller doses ; but 
codeine will be found to possess some advantages over opium or its 
other alkaloids, though Fraser and Bruce strongly believe in the 
superiority of morphine. 

Codeine is less likely to cause disturbance from its narcotic action, 
being a much weaker narcotic than morphine, and the good which 
opiates unquestionably accomplish in diabetes is altogether independent 
of their anodyne properties, and Bruce has shown, when they are ex- 
ercising their best effects in diabetes, that narcotic symptoms seldom 
are manifest. Fraser insists that codeine should simply be regarded as 
weak morphine. The dose of codeine may commence with i grain, 
increased to 2 or 3 grains, three or four times a day. It will be found 
not to interfere with digestion, and is always well borne. Under its 
influence the amount of sugar generally markedly falls in a few days. 
Fraser found that the therapeutic value of 1 grain of morphine daily 
in diabetes exceeded that of 15 grains of codeine. 

In cases where the codeine treatment with strict diet fails, any of 
the following drugs may be tried. The list might be much further 
lengthened out, as nearly every remedy has got a turn in the manage- 
ment of this serious ailment. 

Antipyrine is placed next in value tj opium and its alkaloids, and 
some recent observers go so far as to state that it possesses more influ- 
ence over the diabetic process than these agents. It must be given in 
full doses, i. e., 10 grains, four or five times a day, to be suspended as 
soon as any albuminuria appears. 

Phenacetin, antifebrin, exalgine, and the other members of 
the same class, appear to have a similar but less certain effect. 



180 DIABETES. 

Carlsbad waters drunk freely at Carlsbad, in conjunction with 
strict dietetic treatment, until the urine becomes alkaline, with or with- 
out the opium or morphine treatment, has given most satisfactory and 
lasting benefits in many cases. It would appear that the Carlsbad 
waters have been proved to be more effectual than the other natural 
alkaline waters — as Vichy, Neuenahr, Fels, or Vals — and it is insisted 
by those at the place, that the drinking of the water at its source is 
much more efficacious than undergoing the treatment at home. 

Alkalies have been much used, and the good effects of the Carlsbad 
water is doubtless owing to their presence. The waters, of Vals and 
Vichy are, no doubt, of value in some cases. The alkaline carbonates 
and ammonia phosphates, the citrates of soda and potash and free 
ammonia, or its carbonate or acetate, have been pushed, but apparently 
with very little influence upon the amount of sugar. Alkalies and 
their carbonates are by Ebstein supposed to act by directly supplying 
carbonates and free carbonic acid to the protoplasm of cells throughout 
the body. 

Saccharin has been vaunted as a cure. It is of great use as a sub- 
stitute for sugar, but here its therapeutic virtues end. Large quantities 
are liable to upset the stomach, and by leaving a permanent sweet 
taste in the mouth may destroy the appetite. Almost the same may 
be said of glycerin. 

Permanganate of potassium and peroxide of hydrogen have 
failed signally in the hands of most physicians. 

Bromide of potassium, salicylic acid, cocaine, bromine, picric 

ACID, CALCIUM SULPHIDE, LACTIC ACID, large doses of QUININE, URA- 
NIUM SALTS, LITHIA SALTS, CREASOTE, and ARSENITE OF BROMINE 

have been reported to have caused cures, but in other hands have 
almost always proved useless. 

Jambul has given very promising results. The dose is 3 to 5 grains 
of the powdered seeds. Saunby, however, states that the drug is 
useless. 

Rennet and pepsin have been used and found wanting, and 
Roberts has given strychnine and belladonna till their physio- 
logical effects have been evident without the least influence upon the 
sugar. Calabar bean and ozonic ether have proved to be com- 
paratively valueless. Sugar and honey have been given with the 
idea of replacing the amount lost through the kidney, but with almost 
disastrous results. 

Massage and electricity, quinine, cod-liver oil, iron, and 
laxatives of the castor-oil or cascara type, are generally useful in 
combating symptoms, or complications arising during the disease. 

Martineau's specific, consisting of an aerated solution of arseniate 
of sodium and carbonate of lithium, has done some good as a nervine 
tonic and diuretic. 

Dujardin-Beaumetz speaks very highly of this treatment, which he 
modifies in the following way : He gives 8 grains of carbonate of 



DIABETES. 181 

lithium in a glassful of Vichy water, with 2 drops of Fowler's solution, 
before each meal. 

Oxygen, pumped into water and given as an aerated beverage, has 
proved very beneficial in some cases. 

The above seems but a small portion of the list of drugs whose 
praises have been from time to time sung in the treatment of diabetes. 
It would appear that many observers, when getting a case of diabetes, 
place it at once upon a diet devoid of sugar and starch, and any drug 
which their fancy induces them to try they prescribe, and often fall 
into the error of ascribing all the good effects to it alone. 

The complications arising during the disease are to be treated upon 
general principles. 

Coma should be promptly met by large doses of free alkalies, or the 
intra-venous injections of bicarbonate of soda solution. 

Recently Reynolds lays great stress upon the necessity of very large 
doses of the citrate of potassium and great quantities of fluids to be 
swallowed by the mouth. He mentions a case w T here he was able to 
dispel approaching coma by ordering drachm doses every hour of this 
salt, and the administration of about two gallons of water in the 
twenty-four hours. 

As soon as the daily examination of the urine shows that the dietetic 
treatment has failed to make any further reduction of the daily excre- 
tion of sugar, or when the greatly reduced amount begins to remain at 
a standstill, then the opium treatment may be commenced. It is a 
mistake to do this without previously ascertaining the daily amount of 
sugar by Roberts's method. 

The diet should be carefully regulated from day to day, and as much 
variety as possible afforded to the patient. Much wall depend upon 
this, for if the patient be allowod to become disgusted by the sameness 
of his diet he is sure to suffer. 

When the sugar has disappeared, a few ounces of bread may be 
tried, and if no sugar appears this may be gradually increased ; but 
sugar should not be allowed, no matter how small the quantity. Pota- 
toes, until the urine has been long free from sugar, should not be per- 
mitted, though they are recommended as a portion of the diet by 
Dujardin-Beaumetz and others. 

The profession is watching with the greatest interest the results of 
the brilliant researches being carried out by Professor Lepine, of 
Lyons, and already there is fair ground for hoping that the outcome 
of these will be the first step in a truly scientific treatment of this 
formidable malady. 

The writer, in conjunction with Professor Brunton, had recently the 
privilege of witnessing some of the steps in these interesting experi- 
ments in the laboratory of Professor Lepine, and, though several 
authorities, including Arnaud and Sansoni, question his theory of the 
bipolar action of the pancreas, there is little doubt but a distinct 



182 DIABETES. 

advance is being made since his discovery of a glycolytic ferment in 
the blood. 

The physician will find a reference to the following diabetic diet- 
aries, which are given in detail, along with much valuable practical 
information, in Yeo's book on " Food in Health and Disease," of the 
greatest advantage during the treatment of this serious and trouble- 
some affection. 

Pavys Dietary. 

The following articles are allowed : 

Butchers' meat in every form except liver ; bacon and ham ; game, 
poultry ; all kinds of fish, both fresh and cured, including the Crustacea ; 
animal soups (without thickening), including beef tea and broth. 

Eggs, cheese, cream-cheese, cream, and butter. 

Almond, bran, or gluten substitutes for ordinary bread. 

Greens, spinach, turnip-tops, water-cress, mushroom, mustard-and- 
cress, cucumber, lettuce, endive, radishes, and celery. 

In moderate quantity, after boiling in much water, are allowed : 

Turnips, French beans, Brussels sprouts, cabbage, cauliflower, broc- 
coli, sea- kale, asparagus, vegetable marrow ; also, pickles, olives, vinegar, 
and oil. 

Jelly, flavored but unsweetened ; savory jelly, blanc mange, made 
with cream and not milk ; custard, made without sugar. 

Nuts of all kinds except chestnuts. 

Tea, coffee, cocoa from nibs. 

Dry sherry, claret, hock, dry Sauterne, Chablis, Burgundy. 

Brandy and spirits, unsweetened ; soda water, Burton bitter ale in 
moderate quantity. 

The following are forbidden : 

Sugar in any form, wheaten bread, and ordinary biscuits of all 
kinds. 

Rice, arrowroot, sago, tapioca, macaroni, and vermicelli. 

Potatoes, carrots, parsnips, beetroot, peas, and Spanish onions. 

All kinds of pastry and puddings, and fresh or preserved fruits of all 
kinds. 

Milk is forbidden, except in very small quantity, and also port 
wine. 

Sweet ales, mild and old porter and stout, cider, liquors, and all 
sweat and sparkling wines. 

Sir William Roberts's Dietary. 

The following articles are allowed : 

Butchers' meat, poultry, game, and fish. 

Cheese, eggs, butter, fat, and oil. 

Broths, soups, and jellies made without meal or sugar. 



. DIABETES. 183 

Cabbage, endive, spinach, broccoli, Brussels sprouts, lettuce, spring- 
onions, water- cress, mustard-and-cress, and celery. 

For bread is substituted — bran cake, gluten bread (and meal), 
almond meal, rusks, and biscuits; also, "Torrified " or charred bread. 

Dry sherry, claret, bitter ale, brandy and whiskey in small quan- 
tities. 

Tea, coffee (without sugar), chocolate (made with gluten meal), soda 
water, bitartrate of potash water. 

The following are forbidden : 

All saccharine and farinaceous foods, bread, potatoes, rice, tapioca, 
sago, arrowroot, macaroni, etc. ; turnips, carrots, parsnips, beans, and 
peas. 

Liver contains much sugar-forming substances, therefore oysters, 
cockles, and mussels, which contain enormous livers, are forbidden ; as 
is, also, the " pudding " of crabs and lobsters. 

All sweet fruits — as apples, pears, plums, gooseberries, currants, 
grapes, oranges, etc. 

Port, and all sweet wines ; sweet ales and porter ; rum and sweet- 
ened gin. 

Seegen's Dietary. 

Any quantity of the following are allowed : 

Flesh of all kinds: preserved (smoked) meats, hams, tongue, bacon. 

Fish of all kinds, including oysters, shell-fish, crabs, and lobsters. 

Animal jellies, aspic, eggs, caviare, cream, butter, cheese. 

Spinach, cooked salads, endive, cucumber, green asparagus, water- 
cress, sorrel, artichokes, mushrooms, and nuts. 

The following in small quantity are permitted : 

Cauliflower, carrots, turnips, white cabbage, green beans. 

Berries — such as strawberries, raspberries, currants; also oranges 
and almonds. 

Beverages in any quantity are : 

Water, soda water, tea, coffee, Bordeaux and Khine and Moselle 
wines; Austrian and Hungarian table wines; in short, all wines that 
are not sweet, and that contain only a moderate amount of alcohol. 

In very small quantities may be taken : 

Milk, unsweetened; almond emulsion; brandy, bitter beer; lemon- 
ade, unsweetened. 

The following are forbidden : 

Farinaceous foods of all kinds (bread only in very small quantity, 
according to the discretion of the physician), sugar, potatoes, rice, 
tapioca, arrowroot, sago, groats ; peas, beans ; also sweet fruits, as 
grapes, cherries, peaches, apricots, plums, and all kinds of dried fruits; 
champagne and sweet wines and beers, must, fruit wines and fruit 
juices and syrups; sweet lemonade; liquors; ice and sorbets; cocoa 
and chocolate. 



184 DIABETES. . 

Cantanis Dietary. 

The following articles are allowed : 

Meat and animal fats of all kinds (at all meals), chopped pancreas 
cooked in bacon fat. 

Fish of all kinds, lobsters ; olive oil (instead of butter), eggs (in 
milder cases). 

Pavy's almond cakes are substituted for bread (only for convales- 
cents, who cannot entirely dispense with bread). 

Pure water, soda water ; persons habituated to the use of strong 
wines and spirits may add to the water 10 to 30 grammes of pure 
alcohol daily. Red wine, tea and coffee in milder cases. 

The following are forbidden : 

Liver ; butter, as it contains traces of lactose ; cheese, milk, all fari- 
naceous and saccharine foods absolutely ; all fruits and green vegeta- 
bles and roots. 

Much salt or much pickled pork or salt fish. 

Lemonade, chocolate, vinegar, rum and Cognac, tea and coffee in 
severe cases. 

Germain See's Dietary. 

The following articles are allowed : 

All kinds of animal flesh, boiled or roasted ; ham, bacon ; all kinds 
of fish, Crustacea, oysters ; eggs, cheese (well-kept) ; fats of all kinds, 
butter, lard, and sauces without flour; 5 ounces of bread or potatoes 
daily, also roots and green vegetables. Saccharin to replace sugar. 

Wines that are not sweet, and tea and coffee without sugar. Vichy 
water is recommended before meals, especially in gouty cases. 

Milk, as a general rule, is forbidden. 

Bouchardat's Dietary. 

The following articles are allowed : 

All kinds of meat (150 to 200 grammes of fat daily), cooked in any 
way, but without meal or sugar. 

All kinds of fish ; lobsters, crabs, oysters ; snails ; eggs and cream ; 
cabbage, lettuce, spinach, artichokes, asparagus, green beans, etc. ; 
peaches and strawberries. 

Gluten bread is to be substituted for bread. 

As a beverage — claret or Burgundy, to the extent of 1 pint to H 
pints daily, is allowable. 

Milk is forbidden, and also all substances rich in carbohydrates. 

Ebstein's Dietary. 

For early breakfast he allows one cup of coffee or tea (black), with- 
out milk and sugar ; white bread toasted, 30 to 50 grammes ; or brown 



DIABETES. 185 

bread, well buttered — butter 20 to 30 grammes. The yolk of an egg ; 
a little fat ham, or some German sausage (if required). 

If any food be required between this meal and dinner, let it be a cup 
or broth, with the yolk of an egg. 

For dinner he allows — broth, with yolk of egg or marrow (the 
marrow-bone is boiled for half an hour to solidify the marrow). Some 
peptone may be added to the broth. 

Meat (180 grammes, free from bone), roasted, boiled, or stewed — 
beef, mutton, pork, veal, fowl, or venison (fat meat preferred). Gra- 
vies, with cream or yolk of egg, not flour. Or fish, with melted butter. 

Vegetables, prepared with much fat ; purees of leguminous plants. 
Salads, dressed with vinegar and oil, and some cream. The food should 
be well salted and spiced. 

After dinner a cup of coffee or tea. 

For supper are allowed one cup of tea or broth, meat roasted, ham 
or cheese, or an egg, or fish, caviare, bread (30 to 50 grammes), with 
butter (20 to 30 grammes). Apples, pears, and stone fruits are allowed 
in small quantities. 

Beer is forbidden, and the use of spirits is limited. Haifa bottle of 
wine daily is allowed. If the patient digests milk well, he is allowed 
it in moderate doses, and cream especially. 

Duhring's Dietary. 

Burney Yeo points out that this dietary differs from most others, and 
is founded on the theory that the most important factor in the causa- 
tion of diabetes in a faulty diet and disturbed digestion. Diihring, 
therefore, insists only on a restricted diet, and the selection of the most 
digestible foods. 

For early breakfast are allowed milk, with a little coffee, but no sugar 
(some lime water to prevent milk from becoming sour in stomach), 
stale white bread ad libitum, or oatmeal, barley, or rice gruel, made 
with water, a little salt, but no butter (if bread cannot be borne). 

For second breakfast are allowed white bread, stale and well baked ; 
an egg lightly boiled, rice or oatmeal gruel, with or without milk (a 
breakfast-cupful) or half a glass of good red wine (with water in cer- 
tain cases). 

For dinner (taken between two and three o'clock) are allowed soup, 
with rice, barley, cr oatmeal ; meat, roast, 250 grammes (game, ham, 
and smoked meats, as free from fat as possible, are permissible) ; no 
condiments, no fatty sauces. 

Compote of dried apples, plums, cherries, dried peas or white beans 
in some cases, green vegetables, asparagus, French beans, carrots, cauli- 
flowers, cabbages (boiled in water with salt, not with fat or stock). 

Dessert of a little raw fruit, apples, cherries, and one small glass of 
red wine, diluted with water. 

For supper (about 7 p. m.) give gruel of barley, oatmeal, or rice, 

13 



186 DIARRHCEA. 

with salt (but no butter), and strained ; in some cases may be made 
with milk. Ice or iced water, to relieve thirst between meals. 

He lays great stress on the mode in which these vegetable foods are 
prepared, especially the cereals used for making gruel, and the legumes 
are, before being cooked, to be steeped for some time, and boiled long 
enough to make them more easily digested. 

DIARRHOEA. 

This condition must not be regarded as a disease. It is but a symp- 
tom of various affections of a widely different nature, and the first duty 
of the physician before treatment is begun is to try and find out the cause 
of the condition. There can be no worse practice than to administer 
opiates in every case of diarrhoea, or to follow the routine practice of 
pouring down drenches of chalk and catechu or other astringents. It 
is a well-known fact, and by no means infrequent in occurrence, that 
severe and persisting diarrhoea may be produced by a mass of old feces 
lying in the large intestine, and in elderly people this cause should 
always be looked out for. 

Most of the cases of acute diarrhoea' met with in practice may be 
classed under the head of " irritative." They follow some indiscretion 
in diet, and especially in adults, may be safely regarded as if the 
patient had taken a cathartic which was irritating the small intestine, 
causing sometimes intense griping and smart purging. Such cases will 
require little treatment, and certainly should not be checked at first. 
The diarrhoea is Nature's method of getting rid of a poison introduced 
from without in the food, or generated within the bowel, and if the 
physician must interfere, it may be best to assist Nature, and give a 
mild dose (2 drachms) of castor oil, or a teaspoonful of Gregory's pow- 
der (pulv. rhei comp.). The severe pain is best combated by a large 
dose of whiskey or brandy, or 5 minims of oil of turpentine or other 
essential oil. 

Salines, though often employed, are not, in the writer's opinion, 
suitable in these cases. They increase the pain, and, by rendering the 
motions quite fluid, may sweep past and not remove the source of irri- 
tation. 

This form of diarrhoea is very common in children fed upon cow's 
milk, and the early diagnosis of it will enable the physician to often 
save life. It can be recognized at once by an examination of the 
infant's napkins, or by a description of them when not available for 
inspection. The motions consist of masses of undigested curd closely 
resembling glazier's putty in appearance and consistence, these masses 
can be easily shaken off or detached from the napkin which they 
scarcely soil. They are often green in color and are passed solid, with 
a little acrid watery discharge often mistaken by the nurse for urine. 
Here the employment of vegetable astringents or opiates means delay, 
and too often death. 

The first symptoms may be rapidly followed by vomiting, and if the 



DTARRHffiA. 187 

cause be not promptly removed, a low and fatal form of enteritis sets 
in which is beyond the reach of drugs. The symptoms are so treach- 
erous that before the physician is summoned this may already have 
taken place. The cow's milk should be instantly stopped, and a 
healthy wet nurse obtained. When this cannot be accomplished with- 
out delay, which is usually the case, two courses are open. Raw meat, 
grated or pounded to a pulp, may be given or made into strong beef 
tea ; or Nestle's milk food should be tried. In emergencies of this 
kind, the writer is satisfied that there is no other food will give such 
good results. He has used it since its introduction into this country 
in 1873, and believes he has often seen it save life, which otherwise 
would have been lost. Directions must be given that no cow's milk 
should be administered until long after the attack is passed, and then 
only in very small amount, and but once a day at first, watching its 
effects. 

It is upon the whole better never to return to it if the attack has 
been a serious one. As soon as the child takes to the new food, a 
smart dose (one teaspoonful) of castor oil should be given to clear any 
indigestible curds out of the bowel. No further drugs are needed in 
the majority of cases. 

Meigs's milk and cream food is an excellent diet, and when cow's 
milk must be returned to, it is the safest. A child six months' old 
may have the following modified formula. The lime-water may be 
replaced by solution of bicarbonate of soda (3 grains to 1 ounce) : 

R . — Pure fresh milk 3 parts. 

Cream . 1J " 

Lime-water . . . ' . . . .1 part. 

Sugar of milk ■ i " 

Boiled water 2 parts. — M. 

Of a different nature altogether is a form of irritative diarrhoea, 
occurring in infants or children a little older, but still very young, and 
known as summer diarrhsea. Here also the milk — generally cow's 
milk — is at fault, and there can be little doubt that the irritant is a 
microbe or ferment which secretes a highly poisonous principle, caus- 
ing profuse and frequent liquid motions, so that severe cases are 
spoken of as cholera infantum. 

It is unfortunate that these names are used in different senses by 
different writers, thus irritative diarrhoea is often called inflammatory. 
The irritative diarrhoea caused by curds of milk in infants is some- 
times spoken of as a " simple " diarrhoea, but if it passes on into 
entero-colitis it becomes an inflammatory diarrhoea. 

The treatment must be the immediate withdrawal of the milk diet, 
and the copious administration of ice or iced water with a purgative ; 
after which Nestle's food, prepared fresh every time, or sterilized cow's 
milk may be given, provided it is clear that prior to the attack there 



188 DIARRHCEA, 

there was no evacuation of the firm, dry putty-like masses before 
described. Castor oil is the safest purgative in these cases ; the fol- 
lowing old-fashioned combination is an excellent one, and a child one 
year old may get a powder twice a day. 

$ . — Sodii bicarb. . . . . . . . . gr. iv. 

Pulv. rhei gr. jss. 

Pulv. cinnamomi . . . . . . . gr. j. — M. 

Sterilized milk is a perfect safeguard against ordinary summer 
diarrhoea, or the more severe cholera infantum, which- is probably 
caused by some pathogenic microorganism. 

It can be best sterilized by being boiled upon a water-bath in small 
bottles for fifteen minute. The writer has long been in the habit of 
having all tubes and bottles soaked in a strong solution of boric acid, 
and he advises a few grains to be added to each pint of milk as it 
comes fresh from the cow in summer weather. 

There is no doubt in the mind of the writer that tubercular disease 
is communicated often through the milk of cows with tubercular 
deposits in the mammary gland, and it is a wise measure to always 
sterilize the milk of bottle fed children for more reasons than one. 

Bismuth, or chalk mixture, with occasional purgatives, the best of 
which is castor oil, is harmless. The following is a good routine 
formula after the diet has been made right; it may be freely given to 
a child one to two years old : 



-Bismuthi subcarb 


. gr. xlv. 


Tinct. opii camph. ..... 


• 3J- 


Glycerini 


. ^ss. 


Mucil. acaciae . . . 


. 3 ss.. 


Aquse cinnamomi ..... 


ad ^iij-— 



-M. 

S. — A teaspoonful to be administered after each loose motion. 

This mixture may be used for a child four years old, by doubling 
the amount of bismuth and trebling the camphorated tincture of 
opium. 

Naphthalin has been used with much success on the Continent. The 
rationale being that it destroys, in the intestinal canal, the putrefac- 
tive or pathogenic microorganisms which cause the diarrhoea ; it also 
sto23S fermentation. It may be given in doses of I to 2 grains, four 
times a day, to two year old children in sugar or wafer paper, and 
this dose may be increased to 5 grains for children six to eight years 
old, and has been found by Rossbach to be valuable in cholera in- 
fantum. 

Salol acts equally well. A child, six months old, may get 2 grains 
three times a day. 

Salicylate of sodium, in slightly smaller doses, may be adminis- 



DTARKHCEA. 189 

tered with half a minim of ol. menthse pip. with the same objects in 
view. 

Resorcin, carbolic acid, creasote, corrosive sublimate, salol, euca- 
lyptus, glycerin of borax, lactic acid, and iodoform have been success- 
fully employed by different physicians, with the view of acting as in- 
testinal disinfectants, and promise to supercede the old-fashioned and 
irrational method of pouring in opium, catechu, kino, logwood, rha- 
tany, acetate of lead, copper, sulphate of iron, and many other so-called 
astringents. 

For the frequent green, foul motions of inflammatory diarrhoea, 
there is nothing better than 1 grain of calomel given in doses of ^ 
grain every hour, for six doses, to a child one year old. 

The writer has had no experience of Illingworth's treatment, which 
is so favorably reported upon by many observers. It consists in the 
administration of -^ grain doses of the biniodide of mercury dissolved 
in iodide of potassium, and combined with doses of 1 grain of choral. 

Irrigation, by inserting a soft rubber catheter into the stomach, and 
washing out until the tepid water used begins to return clear and sweet, 
and afterward adding a trace of corrosive sublimate to the water, has 
been successfully employed. Opium, chlorodyne, chloral, belladonna, 
cannabis indica, chloroform, and camphor may be given to relieve 
pain, check spasm, and diminish increased peristaltic action, in appro- 
priate doses. 

Where the seat of trouble is in the great intestine, disinfectants do 
not reach it, and then Babcock's plan of passing up a large, soft rub- 
ber catheter through the anus, and injecting large enemata of rather 
hot sterilized water, is an excellent one. Rice recommends glycerin 
enemata. 

Where the attack has lasted for a considerable time in the child or 
adult, the same treatment may be carried out, employing the drugs in 
larger quantity, and given opium more freely to relieve the increased 
peristalsis. Half drachm doses of bismuth, with 5 grain doses of the 
pulv. niorphinse comp., may be given to adults every six hours. 

Compound decoction of aloes, B. P., has a very striking effect in 
diarrhoea. It may, in one full dose (1 drachm to an infant, H ounces 
to an adult), cause a firm, natural motion where watery stools have 
been the rule for many days, and it can be administered safely in the 
worse cases, as a morning dose, when the ordinary astringent reme- 
dies are being administered during the day. The writer has obtained 
better results from this drug than from any other after the very acute 
symptoms have subsided. 

Chronic diarrhoea may exist long after the irritants which caused it 
have been swept away. After free purgation by the dec. aloes comp., 
astringent tonics, as the astringent iron salts, may be freely given 
after the diet has been carefully regulated. The pif. plumbi cum opio 
may be given every four hours in doses of 3 grains. The acetate of 
lead may be given every four hours in doses of 2* grains, or J grain 



190 DTARRHCEA. 

of copper sulphate may be administered in pill. A favorite combina- 
tion is the following : 



R . — Tinct. catechu comp. 

Tinct. kino . ■ . 

Tinct. opii 

Spt. camphorse 

Mist, cretse 
— Take two teaspoonful every four hours. Shake well. 



• £iv. 

• 3 iv - 

• 3ij- 

ad §vj. — M. 



The following, among many other remedies, have been found useful 
in the treatment of chronic diarrhoea : 

Dilute sulphuric acid, 20 minims in water every four hours. 

Aromatic sulphuric acid, 30 minims well diluted three times a day. 

Alum in solution, 15 grains, or with sugar in wafers every six hours. 

Iron alum, 5 grains, prescribed as a powder or pill three times a day. 

Nitrate of silver, i grain, in pill before each meal four times daily. 

Arsenite of soda, -^ grain, in solution every four or six hours 
(Trousseau). 

Ammonia (carbonate or chloride), 5 grains every four hours. 

Salicylic acid and salicin, 5 grains every six hours in emulsion. 

Sulphate and oxide of zinc are useful in diarrhoea of phthisis in 
doses of 4 grains every six hours in pill. 

Arsenic (2 minims of Fowler's solution) is very valuable in nervous 
diarrhoea, and more so in lienteric diarrhoea if given before meals, and 
in malarial diarrhoea. 

Capsicum, 2 grains every four hours in alcoholic or summer diarrhoea. 

01. menthse pip., ol. caryophylli, ol. cajuputi, in 3 minim doses, may 
be given on sugar where there is much griping. 

Charcoal has been given as an intestinal disinfectant, but naph- 
thalin or salol is much better in 5 to 10 grain doses. 

Ergot or ergoline, \ grain every six hours with morphine. 

Ipecacuanha, 2 grains every six or eight hours in pill after food. 

Hsematoxylon : The extract of logwood in doses of 10 grains as a 
powder, or dissolved in water, is one of the very best remedies for the 
diarrhoea of phthisis or in tubercular peritonitis. It may be safely 
given to young children. 

Tannic and gallic acids, 5 grains in solution every three or four 
hours. 

Sulphurous, nitric, and nitro-hydrochloric acids are valuable when 
combined with quinine, bark, oak bark, or nux vomica in very chronic 
cases. 

Podophyllin may be employed in hepatic conditions causing diar- 
rhoea with pale stools, \ grain every night in pill. 

Calomel may be given in the same way in 3 grain doses. 

Rhubarb is a favorite remedy, and its purgative action is followed 



DIPHTHERIA. 191 

bv a decided astringent effect. Teaspoonful doses of the aromatic 
tincture twice a day is the most agreeable method of using the drag. 

Pepsin and peptonized foods are most valuable in the chronic diar- 
rhoea of children. 

Coto bark, 5 grains, cotoin, h grain every four hours, are valuable in 
diarrhoeas of phthisis and chronic intestinal catarrhs. 

Enemata containing many of the above may be used with a little 
laudanum and starch. 

Quinine in large doses (10 grains) affords the best method of treating 
vicarious diarrhoea where it is safe to interfere. In ursemic diarrhoea, 
diaphoretics and diuretics are indicated. 

Digitalis and Caffeine are the best remedies where the diarrhoea is 
depending upon congestion of the portal system caused by cardiac 
embarrassment and failure. 

Raw meat and Valentine's beet juice are very useful adjuncts. 
Niemeyer and Trousseau used the former in the chronic diarrhoea of 
teething infants with great benefit. 

Arrowroot, or the old flour ball made by boiling common wheat flour 
in a bag for many hours until it becomes hard and then grating it, is 
recommended by A. V. Meigs in infantile diarrhoea. 

DIPHTHERIA. 

Diet is of the most vital importance, and there are few diseases in 
which feeding should be so closely looked after as in diphtheria, though 
Weber affirms that sudden collapse is not prevented by over-feeding. 
Cormack insisted upon the uselessness of feeding unless pepsin was 
added to the food. This is true only of the later stages of the affection, 
and must be kept in mind. 

Strong stimulating food in large amounts, and in as short intervals 
as possible, should be the rule, so as to maintain the patient's strength. 
He should be kept in bed with light though warm clothing ; his body 
heat must be anxiously watched, especially in the later stages of the 
disease, and signs of coldness of the extremities must be met with 
prompt applications of local warmth. 

Stimulants should not be commenced too early, and in very mild 
cases may not be required at all, but generally stimulants will be 
found necessary, and if the physician can manage successfully to blend 
food and stimulant together it will be well ; as food, stimulant, and 
medicine follow each other so closely, more time for feeding may be 
thus obtained. The best arrangement is to give brandy or whiskey 
with the milk, or good old port with beef tea, or sherry made into wine 
whey. Strong soups (oyster, turtle, or hare), beef jellies, good beef tea, 
or beef juice peptonized (see page 171), or paste made of pounded beef 
to which a few grains of pepsin are added, may be given at short 
intervals. If the disease progresses and emaciation occurs notwith- 
standing the consumption of a large amount of nourishment, and there 



192 DIPHTHERIA. 

appears a fair amount of albumin in the urine, it will become evident 
that the patient cannot long stand the siege unless the digestion be im- 
proved. Everything in the way of food must be peptonized, and 
enemata of peptonized food must be given at shortest possible intervals. 

If the larynx is involved in the disease, the steaming, heating, and 
ventilating of the room as detailed under croup must be carried out. 
In every case, ventillation and a generous supply of fresh, warm air 
must be kept up. Considering the highly infectious and serious nature 
of the disease, it will be the duty of the physician to direct measures 
for the prevention of the spread of the disorder to the other inmates of 
the house. The sick-room, placed if possible under a trained nurse, 
must be isolated, and all articles or persons leaving it must be regarded 
as possible conveyers of contagion. It is a good plan to have a large 
pail of water to which a liberal amount of Condy's fluid has been 
added ; this should be placed outside the door of the room, and into it 
all spoons, knives, forks, plates, cups, etc., should be dropped as they 
leave the hands of the nurse. As a probable source of the original 
virus, house drains, the water and milk supply should be looked into, 
and the part that living poultry (chicke'ns and turkeys) play in causing 
the disease in man should not be forgotten. 

Medicinal treatment directed to the general state of the patient will 
be indicated. Chief amongst the best tried remedies is iron, which 
should be given in large doses ; 20 to 30 minims of the tincture well 
diluted may be given every four hours. If there be much feverishness 
or a dry skin the following is a good routine receipt for an adult : 

R. — Tinct. ferri chlor |jj. 

Liq. ammonii acet. . . . . . . ^iij. 

Glycerini ^j. 

Aquse ad §x.— M. 

S. — Take a tablespoonful in two tablespoonfuls of water every four hours. 

Many substances have been recently strongly recommended upon 
the antiseptic or anti-microbic theory, with a view of destroying in the 
system the microorganism which is supposed to be the cause of the 
disease. Nearly every known antiseptic substance has been adminis- 
tered by the mouth, but with, upon the whole, not very satisfactory 
results. The following have been tried : Bichloride of mercury, or 
the red iodide of mercury, in doses of -fa grain, every three or four 
hours. (Jacobi gives j grain of the bichloride in twenty-four hours to 
a child four years old for one week, diluted to 1 : 6000 or 1 : 10,000 in 
milk or water.) Calomel in 1 grain doses, or the cyanide ^q- grain, 
are advocated. Many Continental physicians strongly recommend 
mercury internally in all cases of diphtheria, and the dosage seems to 
be increasing at a serious rate. The writer has made but limited trial 
of this heroic plan, and is not much impressed in its favor, though the 



DIPHTHERIA. 193 

reports are more than roseate. He still believes that the best results 
internally are to be obtained from large doses of iron. 

Boric acid is given in 15 grain doses, every four hours, and borax 
in similar doses. Either of these drugs may be mixed with the milk. 
Noel believes that they are eliminated by the mucous glands of the 
throat and mouth and act locally upon the disease. 

Oil of turpentine, 3 capsules of 10 minims each, may be given every 
three or four hours, or the oil may be given in emulsion with ether. 

Eucalyptus and creasote have been given in smaller doses. They 
are supposed to act in a similar way. 

Peroxide of hydrogen has been given internally in drachm doses. 

Salicin, salicylic acid, or the soda salt has been given alone, and in 
conjunction with the turpentine treatment, with what appears to be 
success, but it is most fallacious to judge of the effects of a drug in 
diphtheria by comparing the mortality after its use in one epidemic 
with the mortality of previous epidemics, the disease varies so widely 
in different outbreaks and in different localities. 

Sulphur internally has been lately extolled, and it differs from most 
of the previously-mentioned remedies in being perfectly harmless. 
Knaggs, after many trials, found that it could be best administered in 
glycerin, which he " believes greatly enhances the efficacy of the 
sulphur." He gives 1 to 2 teaspoonful doses of a mixture of 3 drachms 
of pure precipitated sulphur, rubbed up with 2 drachms of chocolate 
powder in 6 ounces of glycerin, flavored with a little cinnamon. The 
writer finds that the best method of prescribing sulphur is to mix it 
with orange marmalade. 

Benzoic acid, or benzoate of soda, in large doses, has many advocates. 
z drachm of the soda salt may be given. 

Chlorate of potassium — 10 grains in water every three hours. 

Sulphoearbolates — 10 grains in water four times a day. 

Sulphurous acid — in doses of 30 to 60 minims, well diluted. 

Guaiacum — 30 to 60 minim doses of the ammoniated tincture in 
sherry. 

Liquor potassse — 30 to 45 minim doses, well diluted. 

Sodium hyposulphite and sulphites — in 20 grain doses in water. 

Calcium sulphide — ^g- grain in pill every hour or two hours. 

Solution of chlorine — 15 minims, well diluted, every hour. 

The local treatment of diphtheria is in a very unsatisfactory state. 
Some maintain that if the local lesion be very promptly dealt with, the 
disease will be much modified, or even speedily cured. Others, holding 
that it is a general disease, and liable to cause death, totally independent 
of the membrane thrown out in the air passage, condemn all local treat- 
ment. In our present state of knowledge, unfortunately, we are unable 
to arrive at a definite conclusion upon this very important point. But 
the researches of Pasteur upon the diphtheritic virus have convinced 
the writer that the local lesion must be taken into consideration. This 
observer after cultivating the microbe, filtered out the liquid secreted 



194 DIPHTHERIA. 

by it, and, by the action of porcelain filters, separated the micro- 
organism completely from its own secretion. This latter was abJe to 
produce all the symptoms of diphtheria down to the paralytic phe- 
nomena. It would appear, then, that the microbe, living upon a 
mucous surface secreting a deadly poisonous substance, which is easily 
absorbed into the system, must become a serious local danger, and 
must be grappled with. This is, however, no justification for ignoring 
the grave constitutional state present in so many instances of the 
disease. 

It would therefore appear at first sight that the main. indication in 
the treatment of diphtheria would be to get at the false membranes a 
soon as possible and effect its destruction. This seems a simple matter 
only to those who have not studied the growth of the bacillus in suita- 
ble cultivations. It is proved, for example, that the Klebs-Loeffler 
bacillus, which produces the membrane, is to be found only in its 
growing, active condition in the middle or deeper layers of the mucous 
membrane, and not upon the surface where it can be reached by germ 
destroyers. This fact explains many _ of the difficulties and mysteries 
in connection with the failure of the various plans of local treatment 
in the disease. The physician who keeps painting the surface of the 
false membrane is simply bringing his remedies or agents into contact 
with bacilli, the vast majority of which have already become innocu- 
ous. As will be presently mentioned, some local plans of treatment 
have been recently introduced, which aim at overcoming this dif- 
ficulty. 

Of local methods of treatment there is practically no end, and each 
month adds to their number. 

Caustics are being less and less used. Trousseau applied very strong 
caustic. Bretonneau also urged the destruction of the membrane by 
strong hydrochloric acid, frequently repeated. Jenner strongly re- 
commended one good application of the strong acid to the membrane 
at the beginning. One part of the acid mixed with two parts (by 
bulk) of honey, makes an application of such consistence as to adhere 
to the part brushed over, and it is not so likely to run to surrounding 
healthy parts. 

Strong solution of chloride of iron is used to destroy the false mem- 
brane. Carbolic, strong lactic, and other acids are, or have been, 
freely used to cauterize the local seat of the disease, with such very 
doubtful results that little can be said in favor of strong caustics as 
routine agents in the treatment of the disease. 

After cauterization, or where cauterization is never resorted to, it is 
generally held that no attempt should be made to forcibly peel off or 
tear the membrane from the underlying mucous surface, though some 
insist upon this, and brushes have been devised for its forcible re- 
moval. Attempts have been made to cause the disintegration of the 
membrane by acting upon it with agents which have the power of 
digesting animal substances. Pepsin and papain, or the raw juice — 



DIPHTHERIA. 195 

papayotin — from which the papain is derived, have been applied with 
what some authorities regard as brilliant successes. In the hands of 
others they have led to dismal failures. Finkler's papain, dusted as 
a powder over the surface of the membrane when reachable, is free 
from objection, and further trials may show its value, especially when 
we consider that anything wmich would break up, digest, or disinte- 
grate the false membrane, would then permit of antiseptics being 
brought into contact with the mucous surface beneath it where the 
bacilli are growing actively. 

Another class of remedies has been employed to cause solution of 
the membrane. Foremost among these come dilute solutions of 
lactic acid and lime-water, used as gargles or sprays. The lactic 
acid (dilute) 1 part to 8 of water, may be very freely and often used ; 
1 part to 8 or 10 of lime-water may be also tried, both as a gargle 
and spray, and locally applied with a large, soft camel's-hair brush. 
There is no doubt but these substances possess considerable power of 
dissolving the false membrane. The fumes of hydrofluoric acid, given 
off when flour-spar is acted upon by heated sulphuric acid in a leaden 
vessel, also possesses this power. 

Seibert formerly rubbed in fine salt over the membrane twice daily, 
until it became " corned " or " cured." 

Whatever difference of opinion may exist about the utility of these 
various methods of local treatment, there is an overwhelming mass of 
testimony in favor of repeated applications of mild antiseptic solutions. 
The writer has also satisfied himself of their great value, if not in 
cutting short the disease, certainly in minimizing the risk of septi- 
cemia, and in controlling suppuration and putrefaction in the neigh- 
borhood of the membranous exudations. 

Their value is certainly enhanced by any method which causes pre- 
vious disintegration of the false membrane, and their action is liable 
to be rendered useless by strong corrosive agents, which so alter the 
physical character of the membrane as to prevent these antiseptics 
penetrating its layers to the mucous surface beneath. 

One of the least objectionable and most innocent of these remedies, 
and one which may safely be intrusted into the hands of the nurse 
even when very young children and infants are to be dealt with, is 
boric acid. A saturated solution of the acid in glycerin may be freely 
applied with a soft brush every hour, or oftener, where there is much 
fetor. A solution of 3 drachms in 20 ounces of water may be used 
as a spray or gargle as often as possible without causing any worry 
and annoyance. 

Corrosive sublimate, 2 grains in 1 ounce of water may be brushed 
over the membrane occasionally ; or 1 grain in 8 ounces of rose water 
may be freely sprayed frequently. Loeffler, who has studied the ac- 
tion of the various germ destroyers upon artificial cultivations, finds 
this agent to be the most powerful of the series. Next to it he finds a 



196 DIPHTHERIA. 

3 per cent, alcoholic solution of carbolic acid (i. e., 3 drachms in 12 
ounces). 

Carbolic acid, 1 drachm in 10 ounces of rose water, is a safe, valu- 
able, and elegant spray solution. 

Chlorinated soda solution, diluted with twenty times its bulk of 
distilled water, or solution of chlorine, mixed with thirty times its 
volume of water, may be used with advantage where there is much 
fetor. Chlorinated lime may be used in the same way. Chlorate of 
potash, 5 grains to 1 ounce of water, with or without as much chloride 
of sodium,- is a favorite gargle or spray solution. 

Solution of chloride of lime, 1 part of the strong liquor to 4 of 
water and 2 of glycerin, may be frequently applied with a brush. 

Permanganate of potash, 6 grains in 20 ounces of water, may be 
used as an injection where the nostrils are involved. 

Chloral hydrate, 1 drachm dissolved in 1 ounce of glycerin, may be 
brushed on; or a solution, 10 grains to 1 ounce of water can be used 
as a spray or gargle. 

Oil of peppermint, in its undiluted state, may be freely applied with 
a brush. 

Salicylate of soda, sulphites, sulphocarbolates, sulphurous acid, 
tannin, quinine, chinolin, iodine, resorcin, iodoform, creolin, and 
nearly all the newer antiseptics, may be employed in much the same 
manner, either as a spray, gargle, injection, or in stronger solution for 
brushing over the membrane. The popular remedy, sulphur, should 
not be omitted. It is used as a gargle, i ounce to the pint, and the 
powder is used as an insufflation, or dusted on with a dry brush, 
alone, or mixed with quinine. Sulphur certainly may prove very 
efficacious ; the sulphuretted hydrogen which is given off after its 
contact with the organic matter acts as a powerful germicide. 
Vlemingkx's solution has been used by some practitioners; it is 
more active than sulphur. 

Various inhalations have been employed. They are of great value 
as adjuncts to the more direct treatment, and may be the only avail- 
able means of reaching the disease locally in cross and nervous 
children, who repel all attempts at spraying or brushing out the 
throat. 

Oils of turpentine and eucalyptus, terebene, tar, etc., may be made 
to saturate the atmosphere of the sick-room by mixing them with 
boiling water or steam. Iodine and bromine may be also used in this 
way. 

Dr. Corbin has used mercurial fumigations with success. He makes 
a canopy over the child's cot with hoops, and volatilizes 40 to 60 
grains of calomel, and keeps the patient in vapor for twenty min- 
utes. This method is applicable where the larynx is the seat of the 
disease. 

The most rational attempt to solve the great difficulties surrounding 
the local treatment of diphtheria has been recently made by Seibert, 



DIPHTHERIA. 197 

of New York. Recognizing that all antiseptic or germ-destroying 
agents will be of little use unless the deep layers of the underlying 
mucous membrane containing the active bacilli can be acted upon, he 
has devised a means of applying germicides by local injections. This 
is accomplished by a disc attached to a syringe, and bearing a series 
of fine hollow needles, much as the bristles of a brush are attached to 
its back. By pressing the disc against a piece of false membrane, the 
needles are made to penetrate its depth and lodge in the underlying 
mucous membrane ; by driving home the piston the antiseptic solution 
is lodged in the stratum, where active growth is proceeding. The 
solution which he employs is the chlorine water of the U. S. Pharma- 
copoeia, which must be freshly prepared. About 1 gramme of this is 
injected. By this plan he believes that the agent is brought into 
direct contact with the bacilli and with the pyogenic cocci, which are 
also present. Striking results have been obtained, the local oederna- 
tous swelling and temperature rapidly subsiding. He uses a gargle 
and mouth-wash, a little of which is also to be swallowed; it consists 
of a little iodine and carbolic acid in water. 

Where diphtheria extends to the larynx or trachea, or where it has 
started from or remains confined to these regions, its treatment may 
be carried out exactly on the same lines as laid down for the manage- 
ment of true croup. (See Croup.) 

The question of tracheotomy is discussed under the head of Croup, 
on page 163. 

Intubation of the larynx is especially valuable (according to the 
reports of those who have performed the operation) in the case of 
children under five years of age. 

The insertion of the tube is not difficult. The child is made to sit 
bolt upright on the lap of a nurse with the head slightly backward. 
The mouth is opened widely, and a gag inserted. The operator in- 
troduces his left index-finger, and hooks the epiglottis forward, whilst 
with the right hand he inserts a suitably sized O'Dwyer's metal tube 
upon the. point of an "introducer," passing it under the tip of the 
left index-finger into the larynx. The introducer being withdrawn, 
the tube is pushed home with the left index-finger. After a few 
moments coughing, the tube is generally easily tolerated. 

Its extraction is more difficult, and special forceps are devised, 
made so as to enter the upper orifice of the tube, guided by the tip 
of the left index finger. Once inside the tube, the blades are opened 
and the tube removed. 

Dr. Waxham has invented an artificial epiglottis of metal, which is 
attached to the upper end of the tube. It enables the patient to take 
liquid nourishment with ease. 

The great advantage of intubation, which is still in its infancy, is 
that it will certainly be performed at a much earlier stage of the 
disease than tracheotomy. There cannot be a doubt that the high mor- 
tality after a cutting operation is largely owing to the objections of 



198 DISLOCATIONS. 

the patient's friends, who refuse permission until too late. (See page 
1G3.) Statistics show that, all round, the mortality from tracheotomy 
and intubation are very much alike, but there is a decided advantage 
upon the side of intubation when the very early ages are contrasted. 

Macewen has successfully performed tracheal catheterism with a 
soft gum- elastic or rubber instrument, which differs from the short 
metal tubes of O'Dwyer. The end of Macewen's tube is left project- 
ing from the mouth. 

In the later stages of nearly all severe cases of diphtheria, constant 
irrigation of the nasal cavities and the back of the pharynx of the 
nasal douche or by a syringe is of vital importance. A warm stream 
of any weak, unirritating antiseptic solution may be employed every 
hour, in order to remove all pus or decomposing secretions. 

Diphtheria of wounds is best treated by sprinkling calomel over 
them, or applying a strong caustic, as solid nitrate of silver, chloride 
of zinc, or pure lactic acid. 

Diphtheritic paralysis is best treated by forced feeding or rectal 
alimentation, full doses of iron, quinine, and strychnine, and the con- 
tinuous and interrupted current in conjunction with massage and con- 
stitutional remedies calculated to assist the general nutrition, as cod 
liver oil, change to the seaside, etc. For further details see under 
Paralysis (diphtheritic). 

DISLOCATIONS. 

The first indication for treatment in a case of dislocation is the 
obvious one of taking speedy measures for the restoration of the bone 
to its normal anatomical position. 

If the displacement be seen immediately after its occurrence, in the 
great majority of cases it can be easily rectified by manipulation, as 
the great difficulty in reduction is nor present to any extent. This is 
the reflex muscular contraction which offers such marked resistance to 
the efforts of the surgeon. 

As is nearly always the case, some time has elapsed between the 
receipt of the injury and the visit of the surgeon, and then this reflex 
muscular contraction has developed. 

Formerly force was the remedy always used for overcoming this, 
but the use of the general anaesthetics — chloroform and ether — has 
almost relegated the pulley, cord, and weights to the museums of 
surgical antiquities. Nevertheless force, when judiciously applied, 
will always continue to be a valuable aid in some cases. The aim of 
the surgeon should be to replace the bone by manipulation when 
possible ; as a rule this is easy when the patient has been thoroughly 
chloroformed. 

^By movements of flexion, extension, adduction, abduction, or circum- 
duction, the bone is replaced noiselessly in its capsule the exact nature 
and degree of movement being determined by various factors, such as 




DROPSY — DROWNING. 199 

the formation of the joint, the extent of the rent in its capsule, the 
displacement of tendons, etc. Sometimes when complete narcosis has 
taken place the bone may be, as in shoulder dislocation, easily replaced 
in its socket by the direct pressure of the fingers upon its articular 
extremity. 

When chloroform or ether is not available, or is contra-indicated, 
steady traction is to be made in the direction of the new axis of the 
limb until the resistance of the muscles is almost completely overcome, 
when the bone may be felt to slip into its place with a snap, being 
replaced by the action of its own muscles, as is witnessed in the reduc- 
tion of dislocations of the humerus by placing the heel in the axilla, 
and making steady forcible traction upon the limb. Often, patient 
and gentle manipulation will achieve this without any appreciable 
degree of force being employed, and the writer, when resident surgeon 
in a large hospital for two years, nearly always reduced shoulder dis- 
locations without chloroform in this way by raising the arm upward, 
the bone being manipulated into its socket at a moment when the 
muscles were taken unawares, or during a brief period of relaxation or 
exhaustion. Dislocations of the hip in nearly all recent cases can be 
reduced by manipulation under chloroform. The surgeon uses the 
femur as a lever to replace the head through the torn capsule by exe- 
cuting the movements of flexion, rotation, abduction, or adduction, 
according to the position of the displaced bone. 

In old-standing dislocations considerable force must be used, but 
even then pulleys are seldom required. 

Space does not permit of a detail of the various manipulations 
necessary for the reductions of the numerous dislocations occurring in 
the body. 

After the bone has been replaced the limb must be kept in a state 
of absolute rest for a period varying from one to three weeks, until 
repair has set in in the lacerated capsule and injured- soft structures. 

DROPSY. 

The treatment of this symptom or sign will be mentioned under the 
head of the different diseased conditions which are the causes of the 
accumulation of serous fluid. Thus the treatment of general dropsy 
is referred to under Bright's disease and heart affections, and dropsy 
of the peritoneum under ascites. 

DROWNING-. 

After the patient has been rescued from the water he should be 
turned upon his face for a second or two to permit the escape of any 
fluid. At the same time firm pressure should be made over the abdo- 
men and thoracic margin. The following rules are recommended by 
the, Royal Humane Society; they were drawn out originally by 
Sylvester,: 



200 DROWNING. 

" Rule 1. To maintain a free entrance of air into the windpipe. — 
Cleanse the mouth and nostrils ; open the mouth; draw forward the 
patient's tongue, and keep it forward ; an elastic band over the tongue 
and under the chin will answer this purpose. Remove all tight cloth- 
ing from about the neck and chest. See that nothing is lodged in the 
larynx, pharynx, or oesophagus. 

" Rule 2. To adjust the patient's position. — Place the patient on his 
back on a flat surface inclined a little from the feet upwards ; raise 
and support the head and shoulders on a small, firm cushion or folded 
article of dress placed under the shoulder-blades. If natural respira- 
tion has ceased, instantly proceed to carry out 

" Rule 3. To imitate the movements of breathing. — Grasp the patient's 
arm just above the elbows and draw the arms gently and steadily 
upward until they meet above the head (this is for the purpose of 
drawing air into the lungs) ; keep the arms in that position for two 
seconds ; then turn down the patient's arms and press gently and 
firmly for two seconds against the sides of the chest (this is with the 
object of pressing air out of the lungs. Pressure on the breast bone 
will aid this). 

" Repeat these measures alternately, deliberately, and perseveringly, 
fifteen times in a minute until a spontaneous effort to respire is per- 
ceived, immediately upon which cease to imitate the movements of 
breathing, and proceed to induce circulation and warmth (Rule 5). 

" Should a warm bath be procurable the body may be placed in it up 
to the neck, continuing to imitate the movements of breathing. 
Raise the body in twenty seconds into a sitting position, and dash 
cold water against the chest and face and pass ammonia under the 
nose. The patient should not be kept in the warm bath longer than 
five or six minutes. 

" Rule 4. To excite inspiration. — During the employment of the 
above method excite the nostrils with snuff or smelling-salts or tickle the 
throat with a feather. Rub the chest and face briskly and dash cold 
and hot water alternately on them. After natural breathing has been 
restored proceed to carry out 

" Rule 5. To induce circulation and warmth. — Wrap the patient in 
dry blankets and commence rubbing the limbs upwards, firmly, and 
energetically. Friction must be continued under blankets or over dry 
clothing. 

" Promote the warmth of the body by the application of hot flannels, 
bottles or bladders of hot water, hot bricks, etc., to the pit of the 
stomach, armpits, between the thighs, and to the soles of the feet. 
Warm clothing may generally be obtained from the bystanders. A 
teaspoonful of warm water, wine, warm brandy and water or coffee may 
be given as soon as the power of swallowing has returned. The patient 
should be kept in bed and sleep encouraged. 

" During reaction large mustard plasters to the chest and below the 
shoulders will relieve the distressed breathing." 



DROWNING. 201 

The above method of performing artificial respiration is known as 
Sylvester's. If the stomach should be full of water, pressure made 
upon it may force the water up the gullet during the expiratory 
manoeuvre, and this water may be sucked into the trachea and bronchi 
during the artificial inspiratory act. 

Marshall Hall's ready method is sometimes useful in the absence of 
all assistance. It is carried out by placing the body first on the left 
side and rolling it over with the face downwards, so as to drive the air 
out of the lungs, and then rolling it back again until the face looks 
upwards and the dorsum is in contact with the ground, when the elas- 
tic recoil of the ribs will draw the air into the lungs. These alternat- 
ing rolling movements should be performed about twelve times in the 
minute. 

Howard's treatment consists in first turning the patient upon his 
face, with his forehead resting upon his wrist or forearm to keep the 
mouth from the ground. A firm roll of clothing is placed under the 
stomach, so as to cause the head to be considerably lower than the 
trunk. By pressing forcibly and firmly upon the spine, water is thus 
forced out of both stomach and lungs. The body is then rapidly 
turned over, face uppermost, with the roll of clothing beneath the 
thorax, and the head and neck bent well backward, and the arms 
held above the head by an assistant, who should also keep the tongue 
well forward. The operator, kneeling astride the patient's hips, 
places the palms of his hands upon the thorax over the short ribs, 
with the tip of each thumb upon the xiphoid cartilage. Then, by 
alternating throwing the weight of his body forward for two or three 
seconds and suddenly easing off with a push and resting for three 
seconds, the air is made to leave and to enter the thoracic cavity at 
about the rate of ten times in a minute. 

While the artificial respiration is being performed, other assistants 
may be carrying out friction, massage, and application of heat, etc., as 
before mentioned. 

The induced current may be used by applying one pole over the phre- 
nic nerve in the neck and the other over the sixth interspace between 
the right axillary and mamillary lines, so as to produce vigorous con- 
traction of the diaphragm. The poles should be applied at the 
moment when the artificial inspiratory manoeuvre is being performed. 

The efforts at restoration should be continued for at least half an 
hour, and if there be the slightest sign of returning life at the expi- 
ration of this time, the operator should not cease for one hour longer 
at least. Hypodermic injections of ammonia and ether may be given 
after breathing is established. 

Two minutes' submersion is held to be fatal. The writer has timed, 
at a private seance, a professional swimmer who remained under 
water in a large glass tank four minutes five and a half seconds, his 
features being under observation all the time. The performer was 
slightly exhausted, but in a minute afterward appeared perfectly well. 

14 



202 dupuytren's contraction — DYSENTERY. 

DUPUYTREN'S CONTRACTION OF THE PALMAR FASCIA 

can only be successfully treated by a free division of the contracted 
and thickened bands of palmar fascia with their prolongations. In 
mild cases at the beginning, forced extension and bandaging upon a 
splint applied to the palm of the hand at night, with passive motion 
assiduously kept up during the day, may effect a cure. The writer 
has seen one case, where the little finger was affected, yield to this 
treatment, but as a rule the contraction steadily progresses. 

The free subcutaneous division of all the bands by a stout tenotomy 
knife, and the application of an inflexible splint extending from the 
middle of the forearm beyond the tips of the fingers, is the best method 
of dealing with this troublesome affection. If the contraction returns 
after this treatment there is nothing left but to dissect a flap of skin 
from the palm of the hand and divide each band of thickened fascia, 
continuing the dissection until the fibrous prolongations extending into 
the web of the fingers are completely excised. Kocher insists upon a 
thorough extirpation of the thickened and shortened palmar fascia with 
its extensions, after simple longitudinal, incision of the skin of the palm ; 
he holds that no operation can guarantee against relapse unless it 
include prophylactic excision of healthy parts of the fascia. 

There is still considerable difference of opinion among surgeons 
regarding the relative values of the subcutaneous and open operations. 
These are ably contrasted in a paper in the British Medical Journal, 
by Macready, in February, 1890. Adams operates by the subcu- 
taneous method. This plan, though it does not admit of the excision 
of the fascia, or the remedying of the gouty deformity of the joints, or 
of the division of the bands when they have become calcareous, never- 
theless admits of repetition in cases of relapse, which is a great advan- 
tage over the open operation, as in many cases where this fails the 
relapse is incurable. 

DYSENTERY. 

The treatment of the acute variety of this affection may be summed 
up in the word — ipecacuanha {radix anti-dysenteried). It is most effica- 
cious when given in the early stage, and the best results have followed 
the administration of large doses, though often-repeated small doses 
have led to excellent results. From 25 to 50 grains of the powdered 
root should be given in a bolus, or in large pills (5 to 10 grains each), 
or rubbed up with 3 drachms of syrup and 3 drachms of water, or 
folded up in wafer paper. After its administration the patient should 
be kept in bed, upon his back, and a sinapism over the stomach dimin- 
ishes the risk of vomiting. Liquids and all food should be avoided 
for a few hours, small pieces of ice only peing permitted. 

Vomiting does not often follow, and should it occur, the remedy 
may be repeated in a few hours again. Two such doses during the 
twenty-four hours in a few days dispel all tenesmus and diarrhoea. 



DYSENTERY. 203 

A preliminary dose of opium or a small hypodermic of morphine may 
be tried where nausea already exists, but such precautions are seldom 
necessary, as there is generally a very marked tolerance of the drug 
in dysentery. When the symptoms of the disease subside, and the 
motions become distinctly feculent, the dose may be considerably 
diminished. 

Some practitioners give 5 to 10 grains every four or six hours, com- 
bined with bicarbonate of soda and carbonate of bismuth, with a little 
opium. 

Astringents and full doses of opium are not only useless, but do 
much harm in the acute stage of the disease. 

When malaria is present, full doses of quinine must be given, 
and it is a good plan to administer the ipecac in the morning and 
at night, and one large dose (20 grains) of quinine in the middle of 
the day. 

The diet must be carefully regulated, and only liquid food per- 
mitted. Strong soups and milk, with arrowroot and mild stimulants, 
can be administered with safety, and the general management already 
mentioned under Diarrhoea is indicated. The hot bath is of great use 
in relieving pain and tenesmus. 

Children may be similarly treated, and a child two years old may 
get 4 grains of the powdered root night and morning. 

In the chronic disease ipecacuanha may be tried, but often fails. 
The first thing in such a case is to effect the removal of the patient 
from his old surroundings, to change his food, improve his blood, if 
there be any purpura present, by the use of pure fresh lemon juice, 
and keep him at rest in a warm, well-ventilated room. 

Ten grains of the powdered ipecacuanha may be given every eight 
hours, and if speedy improvement does not appear to supervene astrin- 
gents must be tried. The best of these is 1 grain of nitrate of silver, 
combined with three grains of ipecacuanha, and i grain of morphine 
every six or eight hours. 

Ten grains of gallic acid may be given every four hours, or 3 grains 
of acetate of lead, combined with 1 grain of powdered opium ; sulphate 
of copper, sulphate of zinc, and sulphate of iron may be tried. A 
favorite remedy is the liquor ferri nitratis in 30-minim doses, largely 
diluted, every six hours, or 10 minims every hour. 

Castor oil has been used at different stages of the disease with some 
benefit, and calomel was formerly given, but is seldom indicated. 
Any of the vegetable astringents may be tried. Enemata of starch 
and opium often give great relief to the tenesmus. Where the mischief 
appears to be confined to the lower part of the great intestine, much 
benefit in very chronic cases may be obtained from rectal injections of 
nitrate of silver. Eight grains dissolved in 20 ounces of warm distilled 
water may be used to wash out the rectum, or a small enema, 3 grains 
in 2 ounces of water, may be thrown up with the view of being re- 
tained. 



204 DYSIDROSIS — DYSMENORRHEA. 

Alum (1 : 25) and creolin (1 : 200) have been used as injections with 
some benefit. Indian authorities are divided upon the utility of the 
Bael fruit in dysentery. In the acute affection good results have been 
recently reported from J minim doses of tincture of aconite half hourly 
for eight hours, and afterward hourly till pain and tenesmus subside. 
Naphthalin, corrosive sublimate, cannabis indica, turpentine, eucalyptus, 
creasote, iodine, and nearly every antiseptic, have been recommended 
and used with varying success. 

DYSIDROSIS. 

Any soothing ointment in the early stage will relieve itching ; the 
best application will be 1 drachm of the liquor carbonis detergens, with 
1 ounce of cold cream or vaseline. When the vesicles appear the 
patient should be at once put upon full doses of arsenic and a liberal 
diet ; 5 minims of Fowler's solution need not be exceeded. Consider- 
ing that the hands, and sometimes, though rarely, the feet, are the only 
parts of the body attacked, the local treatment is easily carried out. 
Tilbury Fox recommended diuretics, but the writer has never seen 
any necessity for acting upon the kidneys with the view of relieving 
the tension in the minute vesicles. Iron, combined with the arsenic 
at a later stage, appears to prevent new crops making their ap- 
pearance. 

DYSMENORRHEA. 

Dysmenorrhea must be regarded as a symptom common to several 
conditions, local and constitutional, and its successful treatment can 
only be arrived at after a careful diagnosis of the cause of the pain. 
The difficulty is not lessened by the various attempts at classification, 
some authorities describing many distinct varieties of dysmenorrhoea 
whose existence is denied by others. 

Much difference of opinion exists about the possibility of dysmenor- 
rhoea being caused by mechanical obstruction, and without entering 
into this vexed question one may say that there cannot be a doubt but 
large numbers of cases of painful menstruation have been permanently 
cured by dilatation of the external or internal os. It is just possible 
that the dilatation strikes deeper than merely causing a widening of 
the cervical canal ; it may relieve a congested or inflamed condition of 
the lining membrane which may be the cause of the dysmenorrhoea. 
The writer has been often struck with the speedy and permanent cure 
of gleet and chronic urethral discharges after dilating the urethra to 
its fullest size. 

Where the symptoms of obstructed flow are present, and the patient 
suffers intense pain of a paroxysmal character which compels her to 
take to bed at each menstrual period, a careful examination may reveal 
obstruction at the os internum or os externum, or the narrowing may 
be caused by a sharp or acute flexion of the uterus, especially retro- 



DYSMENORRHEA. 205 

flexion. Should this latter condition be found present, it should be at 
once remedied by a suitable pessary. 

Where there is distinct evidence of a marked narrowing of the 
cervical canal or internal os, there is a fair ground for expecting relief 
by dilatation. The operation may be performed in various ways : 

1. Gradual dilatation of the canal and internal os, by means of 
vulcanite or solid metal tapering bougies introduced at intervals of 
several days. 

2. Sudden dilatation, by introducing one size of bougie after 
another at the same sitting, until the canal is restored to its normal 
extent. 

3. Rapid, forcible dilatation, by a forceps-shaped instrument intro- 
duced through the internal os and the blades separated. 

4. By the introduction of sponge, laminaria, or tupelo tents. 

All these methods are unsatisfactory, and soon permit of the dilated 
part returning to its previously narrow state ; and there is, moreover, 
serious danger in using tents, especially sponge tents. The strictest 
antiseptic precautions are always necessary. 

Madden's method, which differs somewhat from former operations, is 
the most satisfactory. He operates at about one week after menstrua- 
tion. After repeated vaginal douching with hot water, the patient is 
placed (under chloroform or ether) in the usual left lateral semi-prone 
position, and Simpson's original metrotome passed into the uterus, and 
two free incisions made the entire length of the uterine canal. Having 
washed the uterine cavity free of all clots by a stream of very hot 
water, he introduces a very simple dilator designed for the purpose, 
and, before it is withdrawn, by pressing upon the handle the canal is 
dilated to any desired extent. The amount of dilatation can be easily 
seen by an index, and sufficient force is used, by withdrawing the 
instrument with the blades apart, so as to tear asunder and distend the 
cut surfaces to such an extent that the index-finger can be passed into 
the uterine cavity. The uterus is again washed out with hot water, 
and a tampon of cotton wool, saturated with glycerin of carbolic acid 
(1 : 4), left in situ for some days. After ten days a flexible tube or 
uterine stem pessary is worn for about a month. Some authorities 
strongly condemn this form of pessary. 

Marion Sims divided the external os with scissors, and the internal os 
with a long blunt-pointed knife. 

Recent experience proves that Apostoli's method of using the strong 
continuous current has a powerful influence over obstinate dysmenor- 
rhea, associated with a narrow pin-hole os and conical cervix. 

Neuralgic or spasmodic dysmenorrhea calls for rest in bed, when 
this is possible, during the attack, aud a hot hip-bath, or the immersion 
of the feet and legs in hot water and mustard. Anodynes must be 
given with great caution, chiefly on account of the danger of establish- 
ing the morphine habit. Alcohol, for similar considerations, must be 
seldom permitted. 



206 DYSMENORRHEA. 

Where the agonizing pain is unusually severe, chloroform or ether 
may be administered sparingly. A hypodermic injection of k grain 
of morphine, with 1 minim of solution of atropine (1 : 100), may be 
given ; \ to I grain of morphine may be given in the form of a pessary 
or suppository ; or 1 to 2 grains of watery extract of opium in sup- 
pository ; or 30 minims of laudanum as an enema, with a little starch 
water. 

Chloral, in 15 to 20 grain doses, relieves spasm and induces sleep. 

Than cannabis indica there is no safer anodyne, and small pills, 
containing -^ of a grain of the extract, may be given every hour for 
six hours. The writer prefers this drug to opiates in dysmenorrhea. 

Belladonna, 3 to 5 minims of the succus, every hour for six hours. 

Butyl-chloral 2 grains in pill every hour for six hours. 

Nitrite of amyl, by inhalation, or \ minim every hour for six 
hours. 

Nitro -glycerin. A tablet (y^-Q grain) may be divided into eight 
fragments, of which one may be taken every ten minutes till relief is 
obtained. 

Cajuput oil may be given in doses of 1 drop on sugar every hour 
or two, until 12 minims be taken. 

Sumbul, in doses of 15 minims of the tincture, every two hours. 

Castor eum has been highly praised by Champneys, who states, in 
his Harveian Lectures, that he has known cases treated by nearly, if 
not quite, all the usual drugs unsuccessfully, which got well suddenly 
as soon as this drug was given. It is best given in the form of tincture, 
20 or 30 drops three or four times daily during the pain, with or with- 
out a few drops of tincture of nux vomica. 

Guaiacum, alone or with sulphur, is also much used by Champneys. 

Camphor, 2 grains in pill or 5 minims of the spirit every two hours, 
may be tried. 

Apiol, in capsules containing 3 minims each, may be given every 
two hours for six or eight times. It is very useful where severe pains 
precede, for a time, the appearance of the flow. 

Electricity, in the form of the continuous current, is valuable in 
this variety of the affection, especially if the flow is habitually scanty. 
Twenty Lelanche cells may be used, with one pole placed over the uterus 
or ovarian region, and the other applied to the sacral region. Intra- 
uterine application is much more effectual, if there be no objection to 
its use. 

ANTiPYRiNE, ; in 10 grain doses every four or six hours, sometimes 
gives great relief, and is free from the objections to which narcotics are 
liable. 

Gelsemium, in 5 minim doses of the tincture every two hours. 

Hamamelis, in "the form of hazeline, may be given in doses of 20 to 
30 minims every hour for ten or twelve hours. 

Ergot, by stopping the irregular contraction, sometimes gives relief 
in moderate doses. 



DYSMENORRHEA. 207 

Bromide of sodium, potassium, or ammonium, in doses of 30 
grains every four or six hours, relieves spasm and diminishes pain. 

Valerianate of zinc, asafoetida, musk, guaiacum, and saline 
purgatives have been successfully used in many cases. 

The passage of a graduated bougie, though no evidence may be 
present of any marked obstruction, has often led to most satisfactory 
results in spasmodic or neuralgic dysmenorrhea. 

Champneys points out that the os internum is the sensitive point for 
the uterus. By stretching this, years of dysmenorrhoeal agony are 
concentrated into a few minutes ; the irritability of the uterus is ex- 
hausted ; it rests, and has a chance of starting afresh — a chance it may 
or may not accept. He looks upon dilatation as the last resort. It 
should be done under an anaesthetic. 

Caulophyllin (1 grain every two hours), viburnum opulus, 
viburnum prunifolium (1 drachm of liquid extract), anemone 
Pulsatilla (2 minim doses of the tincture every two hours), are 
remedies of some use in amenorrhea, and have often given good results 
in dysmenorrhea. 

Hydrastis has lately been favorably reported upon. 

Conium, by the mouth, or in the form of a suppository, is also being 
tried with apparent advantage. 

The treatment of this variety of dysmenorrhea, in the intervals be- 
tween the attacks, is of the utmost importance. Everything that im- 
proves the general health must be insisted upon, chiefly open-air exercise 
to the fullest extent, and active amusements or domestic work within 
doors, plain nutritious food, good hours, and warm clothing, especially 
about the lower extremities. 

There are few details of greater importance than this latter. Thick- 
soled boots and woolen stockings are essential adjuncts in the treatment 
of this variety, as they are in the management of the inflammatory or 
congestive form of dysmenorrhea. 

Ansemia must be combated with large doses of iron, and any evi- 
dence of neuralgia of the superficial nerves should be treated by a 
prolonged course of arsenic and quinine. 

Tonics, like strychnine, nux vomica, mineral acids and vege- 
table bitters, Easton's syrup, or valerianate of zinc, may be 
freely given. 

Rheumatic or gouty tendencies are credited with causing this affec- 
tion, and though this is doubtful, nevertheless colchicum, guaiacum, 
iodide of potassium, salicylates, and alkaline carbonates may 
be ordered. 

Constipation should be met with cascara sagrada, combined with 
glycerin and nux vomica, and errors in digestion met with bismuth, 
pepsin, creasote, etc. 

Champneys concludes his Harveian Lectures (1890) with an able 
discussion of the ethics of the treatment of dysmenorrhea, which should 
be read by all who wish to get a clear idea of the difficulties surround- 



208 DYSMENORRHEA. 

ing this delicate question. There is no doubt about the necessity for 
postponing the first vaginal examination in young virgins as long as 
possible, and when the symptoms warrant a local examination, the 
authority just mentioned advises that it should be made by the rectum, 
at least in the first instance. 

The congestive or inflammatory form of dysmenorrhoea, if brought 
on by a sudden chill during the beginning of a menstrual period, must 
be met by promptly immersing the patient in a very hot bath, hot sitz- 
bath, hot pack, or hot mustard and water foot-bath. After coming out 
of the bath a large mustard and linseed poultice should be placed over 
the loins. 

Hot vaginal douches are valuable at this stage, and small doses of 
aconite every half hour, combined with a diaphoretic or with cimici- 
fuga, may be tried. The following is a good combination : 

K . — Tinct. aconiti 1T|vj- 

Liq. ammon. acet. . 



Tinct. cirnicifugae . 
Aquae chloroformi 
S. — Take a tablespoonful every hom 



ad ^viij. — M. 



Urgent pain must be relieved by opium, morphine, chloral, cannabis, 
or any of the remedies previously mentioned upon page 211. Leeches 
applied to the os have given speedy relief, and a few full doses of ergot 
are often valuable by correcting the irregular contraction. In con- 
gestive dysmenorrhoea, coming on regularly every month, without any 
causes being present suggestive of a chill or suppression of the men- 
strual flow, plethora will be found to play an important part. In such 
cases free purgation with saline cathartics is the best treatment. 

R . — Magnesii sulphatis ^ jss. 

Acidi sulphurici dil gj. 

Antimonii et potassii tart. . .... . gr.j. 

Aquae menthse pip. .• . . . ad ^ x. — M. 

S. — Take a tablespoonful every three hours, until liquid stools are produced. 

A full dose of blue pill or any other mercurial before the saline is 
beneficial. It is in these cases that the saline springs are valuable — 
Carlsbad, Pullna, Vichy, etc., but there is no remedy equal to the plain 
Epsom salt. Active exercise and a well-regulated diet is of the great- 
est importance in the intervals between the attacks. 

The treatment of membranous dysmenorrhoea has been hitherto very 
unsatisfactory, but the recent applications of Apostoli's method of using 
strong continuous currents have given sometimes excellent results. 

Playfair has had great success in the treatment of membranous dys- 
menorrhoea by using the negative intra-uterine current up to 50 milli- 
amperes, and this bids fair to be the only method worth trying in this 
most obstinate form of painful menstruation.. 



DYSMENORRHEA. 209 

This is also the best treatment for the chronic endometritis, which is 
often the cause of the complaint. The galvanic current is used at inter- 
vals during the attacks, and the large clay abdominal electrode is con- 
nected with the positive pole of the battery, while the negative elec- 
trode, properly guarded, is introduced inside the uterus, and a current 
allowed to flow for about ten minutes. The strength may vary from 
25 to 200 milliamperes, but rarely will it be necessary to exceed 50 to 
70. Twice a week during the intervals between the passing of the 
membranous casts will be enough for all ordinary cases. 

Improvement of a moderate kind has followed the use of the con- 
tinuous current when applied externally with one pole over the uterine 
region, and the other over the sacrum. Nevertheless, in those cases 
where the physician does not wish to suggest or carry out intra- uterine 
treatment, the external application of a strong continuous current, say 
from 30 Leclanche elements, may be followed by such benefit as will 
render Apostolus method unnecessary. 

Champneys advises the scraping out of the uterus repeatedly with an 
irrigating curette flushed with antiseptic solution, preceded by dilata- 
tion. 

The violent pain during the attack must be met by anodynes and 
hypodermic injections of morphine, a very mild inhalation of chloroform, 
or sometimes the nitrite of amyl may be enough. Castoreum, anti- 
pyrine, cannabis indica, chloral, and the other remedies may be tried 
with advantage when the peculiarity of the patient forbids the ordinary 
narcotics being administered. 

The danger of the opium, chloral, or alcohol habit becoming estab- 
lished, must be ever before the physician, especially as the diseased 
condition is a very chronic one. 

The general treatment during the attack will, in the main, correspond 
with that of spasmodic dysmenorrhoea. (Page 205.) 

The bowels must be carefully attended to, and between the intervals 
everything that will improve the general condition should be insisted 
upon. Tonics are indicated, and of these there is no drug equal to 
arsenic in moderately large doses, say 4 or 5 minims of Fowler's solu- 
tion thrice daily after food. Belladonna often does good when ad- 
ministered for three or four days previous to the attack ; it shonld be 
given in doses of 10 to 15 minims of the tincture four times a day. 

Removal of the appendages has been recommended, and in one case 
is said to have been successful. 

The treatment of so-called ovarian dysmenorrhoea resolves itself into 
the management of the abnormal condition of the ovary. The most 
important remedy is the constant current applied by means of one pole 
over the ovarian region, and the other over the sacrum. The induced 
current should be tried every third or fifth week in a similar way. 

Bromide of sodium should be given in full doses, 15 grains, three 
times a day during the interval, and as the expected menstrual period 
arrives this dose should be doubled to blunt the sensibility. The iodide 



210 DYSPEPSIA. 

of sodium has succeeded after the failure of the bromide ; they may be 
combined advantageously. 

A smart purge is of great value, and if there be a prolapsed ovary 
the rectum should be kept empty by copious enemata of warm water. 
After the establishment of the flow the bromide and iodide treatment 
may be stopped for fourteen days, during which small doses of arsenic 
and iron may be given with advantage, and moderate doses of quinine 
may be substituted occasionally. During the attacks Indian hemp and 
opium, chloral, or even chloroform may, in some cases, be required. 

Counter-irritation and hot stupes with warm water injections, hot 
baths, and local hot packs afford relief. Where there is evidence of 
ovarian congestion leeching relieves the symptoms promptly. Any 
remedy which obviates the constant use of narcotics should be per- 
sisted in, and 10 grain doses of antipyrine, or 5 grains of antifebrin are 
often invaluable, and may be safely used for long periods. 

DYSPEPSIA. 

Acute attacks of dyspepsia generally depend upon some error in diet, 
and, as a rule, rapidly subside when the cause is removed. Total ab- 
stinence from food for eighteen hours will often be found to entirely 
remove all symptoms. Painful attacks of acute dyspepsia generally 
are cut short when vomiting occurs, and this occurs to the physician 
the wisdom of giving an emetic and clearing out the contents of the 
stomach. If there be ineffectual attempts at vomiting already estab- 
lished by the patient there should be no delay in giving 30 grains of 
powdered ipecacuanha, or 30 grains of sulphate of zinc, or a table- 
spoonful of mustard in a large tumblerful of water, followed by copious 
draughts of warm water till the stomach is thoroughly washed out. 
Though there be no efforts or inclination to vomit when the patient is 
first seen, if there be very severe pain, it will be good practice to give 
an emetic. Warm infusion of chamomile, in teacupful doses, is a 
splendid emetic in these cases. Should a considerable period have 
elapsed between the taking of a heavy meal and the patient being vis- 
ited by the physician, and there be evidence of undigested food in the 
intestines, a smart purge will give speedy relief. 

This may also be tried in those cases where vomiting has not already 
given relief. One ounce of Rochelle salt, dissolved in a tumblerful of 
aerated water, or 2 ounces of the mistura sennse comp. answer well. 
Epsom salt, or any purgative, however, may be given with advantage. 

There should in all cases be abstinence from solid food. Small quan- 
tities of milk and kali water, or of arrowroot, should be taken at short 
intervals, and when nausea is distressing ice may be given, and tea- 
spoonfuls of Brand's essence or Valentine's meat juice. Should vom- 
iting persist, morphine may be given, and by far the best form for the 
administration of the drug in such cases is a pilule or perule containing 
not more than y 1 ^ grain, and made up into the smallest possible bulk 



DYSPEPSIA. 211 

and finished in globular form with a thin gelatin coating. Such are 
made by most pill manufacturers, and are a valuable addition to ele- 
gant pharmacy ; they can hardly be rejected, even if the vomiting be 
continuous. An effervescing mixture containing hydrocyanic acid (2 
minim doses) may be given. 

Bismuth, in the form of subcarbonate or oxide, in doses of 5 to 10 
grains, is a favorite remedy. The writer has seen little benefit from it 
in the vomiting of acute dyspepsia. One large sinapism over the 
stomach may stop the nausea and vomiting at once. The quantity of 
liquids permitted should be very limited, and stimulants are often inju- 
rious. Teaspoonful doses of good old whiskey, mixed with 1 ounce of 
soda water, will be the least objectionable. 

The return to ordinary diet should be postponed for some days, during 
which the patient may live upon light farinaceous food, or milk pud- 
dings, with beef tea or chicken soup, rennet, etc. 

Where the recovery from the acute attack is slow or incomplete, or 
where the first attack is followed by a series of subsequent attacks, the 
treatment detailed under chronic dyspepsia will be indicated. 

Chronic dyspepsia is one of the most obstinate affections which the 
physician has to deal with, and his chief object before commencing 
treatment should be to determine, if possible, the cause. There can be 
little good results obtained by feeding the patient upon drugs or chem- 
icals while the cause of his ailment may be mental worry, gluttony, 
alcoholism, sedentary occupation, or other violation of some important 
law of health. 

The diet should be most carefully attended to, and advice given, 
after minute cross-examination, upon this point. It will often be found 
that the patient has been injuring his stomach by habitual and unvary- 
ing adherence to some restricted form of diet, while he has, owing to 
some pre-conceived error in judgment, been abstaining from articles of 
food necessary to life. He may be, however, only paying the penalty 
due to constant gormandizing or general excess in eating and drinking. 

Speaking generally, one may say that it is a mistake for the phy- 
sician to have a stereotyped dietary cut and dry for every form of 
stomach ailment, though this is a popular and "taking" method of 
treating stomach complaints. 

Few cases of irritative dyspepsia come before the physician in which 
he will fail, after proper painstaking, to discover one or more serious 
errors constantly made in diet. The correction of these errors may 
alone afford the best or only method of treating the disorder satisfac- 
torily. 

It is not unusual to find dyspeptics living upon a diet so restricted as 
to seriously interfere with the general nutrition, because they attribute 
the discomfort following eating, to one food after another, until but a few 
remain upon which they strive to live. After a time, irritative dys- 
pepsia gives way to a hopeless atonic condition. Thus, vegetables are 
at first found to cause such distress that their use is gradually given 



212 DYSPEPSIA. 

up, and when the patient comes under observation he may be suffering 
from a condition bordering upon scurvy. 

It will be found difficult or impossible to lay down a hard and fixed 
law about certain articles of food in dyspepsia, but there are certain 
dishes about which one can speak as being generally liable to serious 
objectious. Thus, pork, pastries, veal, broiled or stewed meat, re-cooked 
meat, rabbit, salted or corned beef, sweetmeats, cheese, eggs, crabs, 
lobsters, nuts, pickles, crude vegetables, especially young potatoes, car- 
rots, parsnips, turnips, cucumbers, and fresh bread, should be forbidden, 
or only taken in very small quantities. 

Beefsteak properly cooked upon a gridiron, with all charred por- 
tions carefully rejected, is the most digestible animal food that the dys- 
peptic can eat. Koast beef and mutton, game, poultry, and boiled ■ 
white fish can be taken with impunity in most cases. Vegetables be- 
longing to the cruciferse generally are doubtful or hurtful, though the 
heart of cauliflowers may be used. Vegetable marrow, stewed lettuce, 
and celery are innocent. Farinaceous foods are, generally speaking, 
admissible, though sometimes they aggravate the mischief. 

It is, however, always to be remembered that strong dislikes or 
marked prejudice against any food may cause it to disagree. The writer 
has verified, in his experience, the statement of Flint : " It is never 
advisable for the patient to adopt a restricted range, or any particular 
system of diet. On the contrary, it is important to persevere in 
attempting to digest all the varied forms of wholesome food, not being 
restricted to a meat or a vegetable diet, but aiming to eat like persons 
in health without the need of particular care in the selection. I have 
never known a dyspeptic to recover vigorous health who undertook to 
live after a strictly regulated diet, and I have never known of an in- 
stance of a healthy person living according to a strict dietetic system, 
who did not become a dyspeptic. On the other hand, in a great number 
of cases in which persons have been sufferers for years on a regulated 
diet, health has been speedily regained by simply eating in accordance 
with appetite." The writer has seen serious and nearly fatal conse- 
sequences follow rigid adherence to the raw beefsteak and hot water 
treatment of dyspepsia. 

The following are very common errors which lead to dyspepsia, and 
their correction is of great importance in the treatment of the affection : 
Improper mastication of food, generally caused by haste in eating or 
by want of teeth ; too long or too short an interval between the meals 
(four hours is a good average) ; drinking of large quantities of fluid at 
meal times, especially cold water or cold milk ; the habit of taking 
stimulants, especially wines, and strong tea or coffee in excess between 
meals. Severe mental work or too active exercise immediately after m 
a full meat is very injurious. Breakfast should not be taken imme- 
diately after getting out of bed. 

Hygienic measures, which improve the tone and vigor of the general 
system, are indicated — as suitable clothing ; healthy residence upon an 



DYSPEPSIA. 



213 



elevated, dry situation ; open-air exercise ; sea-bathing ; change of 
scene, and, if convenient, of employment ; with early hours, and free- 
dom from occupations causing high pressure or mental worry. Agree- 
able society, especially at meal times, is of much use, and it is a good 
rule which prevents the dyspeptic from dining alone. The habit of 
reading, while the patient sits at meals, is very objectionable. 

The medicinal treatment of dyspepsia is only to be undertaken after 
a thorough revision of the dietary as before-mentioned. If constipation 
be present, it should be treated by cascara. (See under Constipation, 
page 144.) Purgatives should not be habitually used, but the occa- 
sional use of a mineral water — like Friedrichshall or Harrogate — is 
beneficial. 

Anaemia, when present, must be treated with iron ; though, in irri- 
tative dyspepsia, this drug must be used with great caution. In the 
atonic form it often gives unexpected benefits. 

For the stomach symptoms in irritative dyspepsia, accompanied with 
chronic gastric catarrh, sedatives are indicated, and for routine treat- 
ment, especially when pain is present, the subcarbonate of bismuth, in 
powder, in doses of 10 or 15 grains, is the most innocent gastric seda- 
tive. It may be given in a mixture suspended with mucilage. Hydro- 
cyanic acid may be combined with it. Morphine is of great service, but 
only in doses of very small amount ; the local, not the constitutional, 
effects are required, and this object is gained by doses of ^ ¥ to y 1 ^- grain. 

Magnesia is a valuable gastric sedative, and may be advantageously 
combined with the bismuth thus : 



R. — Bismuth i sub-carb. . . . 




3iij- 


Magnesii carb 




<5iij- 


Morphinse hydroch. . . . 




gr.j.— M. 


Divide in IS equal powders. 






S. — Take one four times a day, one hour after meals. 






Or, 






$ .— Bismuthi subcarb 




3 v. 


Acid, hydrocyanici dil 




3J- 


Morphinse hydroch. .... 




gr. jss. 


Mucilaginis acacipe recentis 




3jss. 


Aquse camphorse q 


s. ad 


§iv.— M. 


S.— One teaspoonful four times a day before food, the 


bottle 


having first been 


shaken. 







Schacht's liquor bismuthi, in drachm doses, is a valuable gastric 
sedative where pain, nausea, or acidity is present. It is undesirable 
to prescribe large doses of alkalies to be taken habitually for long 
periods, though a full dose of bicarbonate of soda often gives speedy 
relief to the pain of irritative dyspepsia where bismuth and other 
remedies fail. Carbonate of ammonia, or drachm doses of the aro- 



214 DYSPEPSIA. 

rnatic spirit in a wineglassful of kali water, will be a good substitute 
for the soda salt. 

Antipyrine, in doses of 5 grains in tablet form, gives temporary re- 
lief, and capsules of creasote are invaluable in some cases. In very 
chronic cases full doses of nitrate of silver (J grain) given before 
meals have a good alterative action upon the irritable membrane. 
It should be given in pilular form, and only for brief periods. Two 
grain doses of the oxide of silver act in a similar way. Oxalate of 
cerium may be tried as a sedative during the intervals of the silver 
treatment. . 

Where much mucus is vomited, astringents like alum (5 grains), 
kino (10 grains), tannin (10 grains), with opium, may be given. 
Counter-irritation by means of sinapisms, leeches, dry cupping, small 
blisters or a band of lint soaked in diluted nitro-hydrochloric acid 
(one part of the dilute acid in ten of water) worn around the abdomen 
under oiled silk or thin mackintosh, often materially relieves catarrhal 
stomach troubles. 

If the dyspepsia be caused by a chronic congestion of the gastric 
membrane caused by valvular lesion, the vessels should be promptly 
relieved by smart saline purges of magnes. salph. in strong solution (8 
drachms in 4 or 6 ounces of water) to ensure emptying of the vessels. 
Afterward dyspeptic symptoms disappear when the cardiac muscles is 
strengthened by a judicious course of digitalis and nux vomica in 
small oft-repeated doses. 

When the gastric trouble is caused by a catarrhal or inflammatory 
condition depending upon a congested liver, a smart mercurial (5 
grains calomel) at night, followed by a saline, will give relief. Should 
the dyspepsia be a part of the phenomena associated with renal dis- 
ease, treatment directed to the uremic state may afford rapid reliei 
(See Bright's Disease, page 77.) Sometimes the sipping of hot water 
frequently through the day may give ease, and dyspeptics often get 
relief by sipping hot water before breakfast. Small doses of the min- 
eral acids, if given immediately before a meal, seem to check the 
secretion of the gastric juice, and in mild cases of irritative dyspepsia 
this treatment sometimes gives relief; it, however, often aggravates. 
After the more acute or painful symptoms have been got under, treat- 
ment suitable to the atonic condition may be cautiously commenced — 
quinine, vegetable bitters, small doses of iron or arsenic. Ipecacuanha 
is very useful sometimes in small doses. 

The medicinal treatment of atonic dyspepsia includes all remedies 
calculated to increase the functional activity of the stomach. Alka- 
lies, if given in small doses before meals, have been demonstrated to 
increase the amount of gastric juice poured out by the enfeebled gas- 
tric glands, and when combined with suitable tonics are a valuable 
means of restoring function and improving digestion. The bicarbo- 
nate of soda is the best, but sometimes the potash, ammonia, lime, or 
magnesia salt may be selected. In large doses, a few hours after meals, 



DYSPEPSIA 



215 



they act in a very different manner, and give relief by neutralizing 
the excess of acid present in the stomach, as mentioned under the 
head of acidity and irritative dyspepsia, and thus are of much value 
in relieving cardialgia and putting an end to acid fermentation. In 
atonic dyspepsia a good formula will be one containing 10 grains, 
bicarbonate of soda, with a few grains of subcarbonate of bismuth, 
and 15 minims of tincture of chiretta in 4 drachms of infusion of 
calumba or quassia to be taken half an hour before each meal. 
As a powder the following is an excellent formula : 



& . — Sodii carb. exsiccat 

Magnesii carb. . . 

Pulv. rhei 

Make twelve of these powders. 
S. — Take one, three times a day, before meals, 



gr. v. 
gr. x. 
gr. vj.— M. 



Oi 



R . — Sodii carb. exsiccat. . 




• Si- 


Pulv. rhei 




• 5vj- 


Pulv. calumbge . 




• 3j. 


Pulv. zingiberis 




• 5 iv - 


Pulv. Doveri . 




. gr. xxxv. 


Qumina? sulphatis . 




. gr. xxv. — M. 


S. — An eggspoonful in a little 


water before each meal ; 


or a teaspoonfnl two 


hours after dinner if pain or acidit; 


t be distressing. 





Notwithstanding the law formulated by Ringer that " acids check 
all acid secretions," there cannot be a doubt about the very great value 
of the mineral acids in the treatment of atonic dyspepsia. 

Their value has been supposed to depend upon their supplying to 
the gastric juice something in which it is abnormally deficient. In 
whatever way they act the digestive process appears to be hastened 
and rendered less painful in some cases, but to produce this effect the 
acid must be given some time after a meal. 

The dilute hydrochloric or nitro hydrochloric acid in doses of 20 to 
30 minims, with quassia, calumba, chiretta, or better still, with nux 
vomica, given after each meal is about the best routine method of deal- 
ing with a chronic dyspepsia caused by deficiency in the gastric secre- 
tion or delay in the digestive process. 



R . — Acid, nitro-hydrochlor. dil. 
Strychninse sulph. 
Tinct. aurantii . 
Tinct. calumbse 
Infusi gentianae 

S. — Take a tablespoonful, with a wineglassful of water, three times a day 
after meals. 



ad 



3YJ. 

gr- J- 

<f xi J-- 



-M. 



216 DYSPEPSIA. 

Lactic, phosphoric, nitric, and other acids are also very useful. 
Pepsin in its various forms is of much value, and many physicians 
prefer to add the enzyme to the food, and so start or complete the 
artificial digestion before presenting it to the patient. It is of little 
use giving it after purely farinaceous food. The wine of pepsin may 
be given with dilute hydrochloric acid after meals. Lactopeptine in 
10 grain doses, with Y V grain morphine, and 2 grains quinine, may be 
given with advantage after meals, with or without bismuth. Pan- 
creatin may be used in the same way. Papain has been used with 
much success by the writer in doses of 2 grains after each meal. The 
favorite recipe for atonic dyspepsia with the late Professor Gordon 
was one containing in each dose — 1J grains iodide of potassium, 5 to 
10 minims ipecacuanha wine, and J ounce infusion of calumba. 

Flint highly recommended 10 grains of salicin in 2 ounces of water, 
swallowed immediately before each meal. 

One minim of Fowler's solution diluted with 2 drachms of water, 
and given ten minutes before each meal has been found to be followed 
with marked benefit in some cases. 

One to 4 drachm doses of glycerin have been given with some bene- 
fit, a little nux vomica may be combined to destroy its intense sweet- 
ness, and some physicians combine with the glycerin 1 or li minims 
of pure carbolic acid and 10 grains of bicarbonate of soda. 

Massage and the continuous current, if regularly used, are of much 
value as adjuncts to medicinal treatment in atonic dyspepsia. 

Wettendorfer, during the treatment of an eczema of the trunk by 
means of an elastic rubber bandage, noticed the entire disappearance 
of obstinate dyspeptic symptoms, and was thus led to treat all cases of 
irritable or painful dyspepsia by compression of the abdomen with a 
broad rubber bandage applied for one hour after meals. The ordi- 
nary hydropathic belt applied over a warm pad, as recommended by 
Dr. Kevin, acts beneficially. 

Washing out of the stomach has been used in some cases with 
marked success. It has also been highly recommended in the dys- 
pepsia of infants and very young children. After the contents have 
been removed, a stream of tepid water, bearing in solution some anti- 
septic as boric acid, creasote, boroglyceride, Condy's fluid, salicylic 
acid, or sulphurous acid, should be passed through the organ in order 
to thoroughly wash it out. 

For the various symptoms arising during the course of chronic 
dyspepsia, the previously mentioned treatment will, in the majority of 
cases, afford relief, but sometimes special measures must be taken. 
Thus for 

Vomiting, the writer has found that the minute perules of morphine 
(tV g ram ) are upon the whole, the most satisfactory treatment. Ice, 
bismuth (5 grains), creasote (1 minim), hydrocyanic acid (3 minims), 
codeine (i grain), arsenic ( r -^- grain), carbolic acid (1 minim), effer- 
vescing mixtures, champagne, chloroform (1 minim), tincture of iodine 



DYSPEPSIA. 217 

(1 minim), ipecacuanha (minim doses of the wine), have been recom- 
mended. This latter has signally failed in the writer's hands. Kou- 
miss, pepsin, papain, pancreatin, lime-water, nux vomica (5 minims of 
tincture), cocaine (] grain), may be tried. 

Counter-irritation over the stomach is useful when sarcinse, with 
very yeasty, acid vomiting, are present. If creasote fails, sulphurous 
acid (1 drachm), sulphite of soda (16 grains), salicylic acid (10 grains), 
bichloride of mercury (-^ grain), sulphocarbolates (20 grains), oil of 
eucalyptus, or of mentha piper. (3 minims). 

Acidity if it fails to yield to alkalies, will not likely yield to acids 
in small doses immediately before meals. The writer has found that 
the best routine treatment is the creasote capsule ; two may be given 
four times a day. (See the various methods of treatment fully dis- 
cussed under the heading Acidity, page 15.) 

Hamilton has, by an exhaustive study of the contents of the stomach 
at different stages of digestion, shown that in acid dyspepsia there is 
a distinct increase of acid present. Lactic and hydrochloric acids are 
normally present during digestion, but at different periods ; and in 
acid dyspepsia it is lactic acid which is in excess. This is caused by 
a prolongation of the stage of lactic acid formation, and is favored by 
the absence of the normal amount of hydrochloric acid. Hence an 
obvious explanation of the benefit sometimes obtained by giving hydro- 
chloric acid in these cases. 

In other cases, however, large amounts of hydrochloric acid are 
formed, and this has been demonstrated to occur even during fasting. 
The only relief in these cases is to be obtained by large doses of alka- 
lies. 

The writer has satisfied himself that many cases of very severe acid 
dyspepsia are caused by great excess of butyric acid, and the cause 
of this is owing to the practice of stewing or baking fat meats for a 
long time at a high temperature in a close oven. The fat undergoes 
chemical change, and after being swallowed it readily ferments ; and 
he has seen the contents of the stomach so highly charged with butyric 
acid that the epithelium of the throat has been removed or excoriated 
during vomiting, producing alarming symptoms. Large doses of 
alkalies, combined with papain, afford the best means of meeting such 
a difficulty. Roberts recommends that antacids should be used in the 
lozenge form, and while wisely condemning the two official antacid 
lozenges, he suggests that the B. P. bismuth lozenge should be made 
without the bismuth, and that 1 grain of chloride of sodium should 
be added in its stead. Vichy lozenges are excellent antacids for the 
dyspeptic. These antacids Roberts believes, when properly used, may 
be regarded as harmless, even when administered for very long 
periods. The bismuth lozenges he advises should not be used until 
after the expiration of three-quarters or one hour following breakfast, 
and one hour or more after[dinner. The U. S. P. troch. sodii bicarb, 
and troch. magnesise may be used. Lime-water possesses very feeble 



218 EAK, DISEASES OF. 

antacid properties, 15 grains of bicarbonate of soda being equivalent 
to about to about half a pint of the liquor calcis. 

Flatulence is often a most obstinate symptom of dyspepsia, and the 
patient should be informed that the regurgitant or expulsive effort 
which he naturally makes in order to expel the gas from the stomach 
always causes air to be swallowed. In this way the gaseous contents 
never diminish, though gallons of gas are belched off in a few minutes, 
and the distress of the patient increases. He should be convinced that 
it is a mistake to make any attempt to " raise the wind." . Friction, 
kneading, or massage of the abdomen may be tried with a view of 
dislodging the imprisoned gas. Many of the previously mentioned 
remedies, which stop fermentation and hasten the digestive process, 
will soon arrest the secretion of gas. Creasote is again of great ser- 
vice. Sulphites, sulphocarbolates, pepsin in large doses, and papain are 
also valuable. Carminatives like ginger, cloves, ol. menth. pip., caju- 
put, etc.; give relief. Charcoal, freshly dried and given dry (wrapped 
up in wafer-paper), or in capsules, affords comfort and assists digestion 
by causing rapid absorption of gas. Poplar charcoal is preferred by 
many. It may be given Avith advantage before meals. Naphthalin 
has been given as a gastric and intestinal disinfectant, in 8-grain doses, 
with varying success. Boric acid is more certain. 

Alkalies, as the carbonates of lime, magnesia, and potash, either 
alone or combined with strychnine, often afford relief. Asafoetida 
should be given by mouth or enema if the flatus is intestinal. Foods 
likely to ferment or decompose should be avoided, as soups, eggs, 
starch, and fruits. A dry diet — beefsteaks and biscuits of charcoal — 
is generally much more suitable than liquid nourishment, and the 
patient should be warned against taking much fluids after meals. 
Sometimes copious drinks of hot or warm water give relief, but their 
use ultimately aggravates matters. Alcoholic stimulants act in a 
similar way. 

EAR, Diseases of. 

The treatment of eczema of the auricle and meatus differs in no way 
from the treatment of eczema in other regions — the free use of an 
ointment in the early stages, containing 60 minims of liquor plumbi 
to 1 ounce of vaseline, with a few drops of a weak solution of the lead 
liquor (1 : 40) dropped into the meatus. After the acute stage is 
passed, liquor carbonis deterg. may be added to the ointment with 
advantage. The meatus should be occasionally filled with warm almond 
oil, and all secretion gently removed by mopping out the passage by 
means of absorbent wool upon a probe. 

Hcematoma of the auricle is best treated by a free incision, and dress- 
ing with a weak spirit lotion (1 : 5), to which bichloride of mercury 
(i grain to 1 ounce) is added. 

Bony growths, or aural exostoses, when blocking up the meatus, are 



EAR, DISEASES OF. 219 

best removed by gouging, by grinding down with a dentist's drill, by 
sawing with the ecraseur, by inducing caries through the use of the 
trephine, or through the use of a strong continuous current ; the various 
methods suggested for dilating the meatus with tents or plugs without 
removing the growths are condemned by the best authorities. 

Inflammation of the external meatus is most commonly caused by the 
presence of small furuncles, boils, or abscesses ; these occur with dis- 
heartening regularity and frequency, and render the treatment of this 
condition most troublesome. 

In the acute and intensely painful stage prior to the pointing of the 
abscess, leeches to the auricle, followed by hot stupes, give relief. 
Cocaine — the pure alkaloid dissolved in warm oil (4 per cent.) — aifords 
some ease when dropped into the meatus. 

Von Stein extols a combination of cocaine with resorcin in ear dis- 
ease. He finds this relieves pain, and increases the absorbent power of 
the bloodvessels, diminishing secretion in a marked degree. He uses 
about 5 grains of resorcin and 25 grains of cocaine in 1 ounce of water, 
and drops a little into the ear, where it is allowed to remain for a short 
time before being soaked out on wool. Abscesses should be opened 
with a fine-pointed abscess knife, and speedy relief follows. 

Since the writer learned that the pathology of these furuncles was 
probably parasitic, he was led to employ a solution of corrosive subli- 
mate in their after-treatment with a view to prevent their recurrence, 
and the result was most satisfactory. 

In one case which had lasted for years, notwithstanding the meas- 
ures employed by more than one eminent specialist, the life of the 
patient was made very miserable for short periods every few weeks. 
The disease did not return after the use of the following solution had 
been commenced, though some years have elapsed. It was dropped 
into the ear twice a day, and afterward once a day, and the orifice of 
the meatus plugged with cotton wool also moistened by the solution : 

R .— Hydrarg. bichlor. . gr. ij. 

Spt. vini rectif . . . . . . . £ vj . 

Aqua? destillatse ad Jiij. — M. 

S. — To be applied to the inside of the ear on cotton wool. 

Where the inflammation of the meatus is general, and not depending 
upon furuncles, leeches, fomentations, and weak astringent injections, 
followed by dry boric acid, speedily cure the disease. 

Fungi — aspergillus flav. and nig. are sometimes found infesting the 
meatus. They may be easily destroyed by the above liquid, diluted 
with an equal quantity of water. Dry boric acid insufflated, or a 
warm, strong alcoholic solution, soon causes their destruction. 

Wax and foreign bodies in the meatus are best removed by syringing 
with warm water. The ordinary India-rubber enema apparatus answers 
very well, and it is hardly necessary to say that the nozzle should not 



220 EAR, DISEASES OF. 

be introduced within the meatus, but should be held within a few lines 
of its orifice, 

The auricle, when pulled upward and backward, permits the free 
flow of water in and out of the meatus, and by persevering for some 
time, the stream, getting behind the cerumen or foreign body, forces 
it out. If this fails, variously-shaped instruments devised for the pur- 
pose may be used ; about the best is a loop of wire, gently coaxed past 
the obstruction and drawn forward. The loop-end of a fine polished 
hair-pin answers all purposes. Forceps, or a very small scoop, may 
occasionally be required. 

Should there be much difficulty in removing the wax, it will be well 
to adjourn operations for a time, as prolonged syringing sometimes 
causes faintness, tinnitus, and deafness, owing to congestion or extrava- 
sation in the labyrinth. The introduction of a little solution of bicarbo- 
nate of soda (lb grains to each drachm) for a few days greatly assists 
in the removal of the wax. Papain also assists the disintegration of 
wax and other concretions. 

Acute catarrh of middle ear, if severe, will be best relieved by the 
application of two, three, or four leeches to the auricle. 

Hot fomentations will encourage the bleeding from the bites, and 
give further relief. Should the pain be severe and the tympanum 
found bulging, an incision with a fine, sharp, double edged knife or 
needle gives speedy relief. 

When the symptoms are not very acute, the case often yields to a 
few inflations of the tympanum by Politzer's bag. By inserting the 
nozzle of an ordinary enema apparatus well up into the nostril of the 
affected side, and forcibly injecting air at the instant when the patient 
is in the act of swallowing a little water, the air is driven through the 
Eustachian tube, and obstructions caused by accumulations of mucus 
may be easily overcome. 

The naso-pharynx may be douched with weak saline solutions — 
boric acid, chloride of sodium, borax, or bicarbonate of soda (100 
grains to half a pint of tepid water). Dry boric acid in fine powder 
may be blown up the nostril by means of an insufflator. 

If the catarrh resists the above treatment, and shows signs of pass- 
ing into the chronic form, the Eustachian catheter may be passed, and 
a weak astringent solution, if there be evidence of much mucus secre- 
tion, should be injected. The strength of the solution varies, but, gener- 
ally speaking, about the strength of an eye lotion — 1 grain of zinc 
sulphate to 1 ounce of warm water. If the tympanic cavity contain 
thickened mucus — the remnants of an acute attack — some experts 
make a linear incision in the tympanic membrane, and, through 
the Eustachian tube by means of the catheter, wash out the cavity 
by a stream of weak alkaline solution injected into the external 
meatus. 

Chronic catarrh of the middle ear is best treated by remedial agents 
directed to the cause of the obstruction often existing in the Eustachian 



EAR, DISEASES OF. 221 

tube, constant inflation of the tympanum by Politzer's method, or the 
Eustachian catheter with attention to diseased conditions of the naso- 
pharynx by local applications, or by the chloride of ammonium 
inhaler. In very bad cases the incision of the membrane, and the 
injection of alkaline solutions, as just mentioned, may be tried, or 
Leil's operation for division of the tensor tympani muscle may be 
suggested. 

Acute purulent catarrh should be treated just as if a case of acute 
simple catarrh of the middle ear, from which at first in cannot be 
distinguished. If perforation of the membrane has already occurred, 
there may be afterward difficulty in getting the opening to close. It 
is better, for this reason, to incise the membrane early if the case comes 
under notice before perforation has accurred. Constant syringing 
with weak antiseptic solutions (10 grains of boric acid to 1 ounce, or 
3 grains of zinc sulphate to 1 ounce of water) must be carefully done 
at least twice daily. 

M. Shield has directed attention to the difficulty in having agents 
in the dry state applied to the interior of the ear, and he has wisely 
recommended the use of small pellets of round suppositories about the 
size of a swan shot, which quickly melt in the meatus and keep it aseptic 
for hours. In this way iodoform, tannin, boric acid, and other agents 
may be easily used by the nurse or patient's attendant. 

Inflation of the tympanum by Politzer's method should be daily 
performed before syringing. 

Mastoid swelling and tenderness may be relieved by one deep 
incision. The condition of the naso-pharynx must be carefully made 
right by local astringents and antiseptics. Gargles — tannin (1 : 30), 
chlorate of potash (1 : 40), carbolic acid (1 : 80) may be employed. It 
is a good plan to brush out the throat with glycerin and carbolic acid 
(1 : 10), tincture of iron and glycerin (1 : 2), or nitrate of silver 
(1 : 20). _ 

Chronic purulent catarrh requires treatment generally for the per- 
forated state of the membrane. Constant syringing with very weak 
carbolic solution (1 : 120), and insufflations of dry powdered borax, are 
the safest means of restoring a healthy condition of the affected parts. 
An instillation of w r arm alcoholic solution of boric acid (1 : 20), or 
of strong spirit of wine, may be tried. 

Mackenzie Johnston has used a solution of papain for cleansing the 
middle ear in cases of suppuration, with the view of causing disintegra- 
tion of the masses of dry pus or debris. He drops in 15 minims of a 
5 per cent, solution into the ear so that it may reach the bottom of the 
meatus. One hour afterward the ear is to be syringed out with warm 
boric acid lotion. Papain should be a good means of treating choles- 
teatoma of the middle ear by means of the syringe and tubes used by 
Dandas Grant. 

The Eustachian tube should be daily kept clear by inflation. 
Exuberant granulations around the perforation may be kept in check 



222 EAR, INTERNAL, DISEASES OF — ECTHYMA. 

by the application of caustics, as the solid or mitigated stick. Ulti- 
mately the opening, if it does not close of itself, may be temporarily 
stopped up by an artificial tympanum of India-rubber, like Toynbee's, 
or of the membrane which lines the interior of the egg of the common 
hen, or the opening may be closed by a moistened plug of absorbent 
cotton wool pushed through the meatus by means of special forceps 
until it rests against the perforated membrane. This plug or wad 
should be renewed every morning. 

Mastoiditis should be promptly met by leeching, and as soon as pus is 
evident a large, deep incision down to or through the periosteum. If 
matter be not reached, and brain symptoms are present, trephining 
should be resorted to without delay. Where dead bone exists, its early 
removal is necessary. 

Polypi, which commonly appear during the course of chronic 
purulent catarrh, should be removed by the snare-forceps or ring- 
knife. 

EAR, INTERNAL, Diseases of. • 

The treatment of the various groups of symptoms found associated 
with abnormal conditions of the nervous structures in the ear is very 
unsatisfactory. 

Syphilitic affections, if of very long standing, are almost hopeless. 
Mercury by inunction in the early stages will give good results. At a 
later period, large doses of iodide of potassium (20 to 30 grains), with 
frequent mastoid counter-irritation, may be tried. 

Tinnitus aurium may be treated, with some slight benefit, by large 
doses of bromide of sodium (30 grains three times a day). The various 
suggestions for counter-irritation of the mastoid, the hypodermic injec- 
tion of nitrate of pilocarpine, electricity, puncture of the tympanum, 
etc., are generally useless, The instillation of cocaine has sometimes 
given considerable relief, and this is supposed to result from its influ- 
ence on arterial pressure. 

Meniere's disease has been treated with occasional success by large 
doses of quinine (5 to 10 grains), bromides (30 grains), salicin or 
salicylates (30 grains) ; digitalis, 10 minims of the tincture, every four 
or eight hours, has been tried along with counter-irritation over the 
mastoid and the continuous current. (See also under the separate 
heading of Tinnitus.) 

ECLAMPSIA— See Puerperal Convulsions. 
ECTHYMA. 

The original affection of which this is the cause must be treated. 
Thus, prurigo, scabies, pediculosis, or any condition or affection of the 
skin accompanied by much itching, may be the origin of ecthyma, and 
this condition will rapidly disappear upon the removal of these causes. 



ECZEMA. 223 

The affection is generally only seen in the filthy, those badly fed and 
unhealthy ; and the indications in such cases are scrupulous cleanli- 
ness, good plain food in abundance, and improved hygienic surround- 
ings, with cod-liver oil, tonics, and proper clothing. The local treat- 
ment must be directed to the primary affection ; crusts and scabs should 
be removed by poulticing or warm water, and a mild astringent oint- 
ment then applied to the base of the pustule. Zinc ointment with J 
drachm of liquor plumbi to each ounce, answers well in most cases. 
Lotions covered by oiled silk are to be avoided. 

ECTROPION— See Entropion. 
ECZEMA. 

The treatment of this common ailment is one of the most difficult 
problems that comes before the physician. Unfortunately, there are some 
cardinal principles about which authorities differ, but too much is made 
out of these differences. The vexed question of the local versus the 
constitutional origin of eczema is a stumbling-block. It appears almost 
certain that both views are correct, and the error to be guarded against 
is the common one of taking either side of the question to the exclusion 
of the other. This, at the start is a matter of vital importance as 
regards treatment. The physician who always regards eczema as a 
purely constitutional disorder, to be purged out or drugged out of the 
system, will continue to treat eczema with internal remedies long after 
the constitutional condition which caused it has been remedied. Upon 
the other hand, he who looks at the ailment exclusively from the local 
standpoint may find himself treating a case of the disease solely with 
topical remedies long after the original local cause which called the 
eczema into existence has disappeared, the condition being, in the 
meantime, kept up by some constitutional error. This constitutional 
error may be a factor possessing enough power to keep up the eczema 
when once produced by a local irritant, though it possibly, of itself, 
might never have been able to establish the disease. Hence the treat- 
ment of eczema must be both constitutional and local, and clinical 
experience amply proves that, upon the whole, the local treatment is 
much more successful in the great majority of cases. 

Diet must be carefully attended to, especially in acute cases, and 
upon the whole, a purely milk diet, in the absence of special contra- 
indications, is the best where any considerable portion of integument 
is involved. 

In chronic cases, a good, generous mixed diet may be permitted, 
but sugar and coffee in any quantity should be forbidden, and all 
salted meats, pork, shell-fish, cayenne, spices, pickles, raw fruits, pastry, 
and cheese, should be partaken of with great caution. Any food or 
article of diet which the patient has found to aggravate the itching in 
the eczematous spot, must not be again indulged in. Some patients 
feel that the smallest sip of wine, in a very short time after being 



224 ECZEMA. 

swallowed, produces tingling and itching in the seat of the eczema, and 
this is especially true if the head, face, or neck is affected. Upon the 
whole, stimulants must be allowed in very sparing quantity, and, 
where indicated, whiskey is the best. Acid wines are especially hurt- 
ful, and English beer, as a rule, should be forbidden. Lager beer is 
much less objectionable. In the presence of dyspepsia, or other gastric 
trouble, the dietary suitable to the patient's needs must be selected. 

Everything that will improve the hygienic condition of the patient, 
as to proper rest, exercise, sleep, clothing, sunshine, cookery, etc., 
must be seen to when found to be faulty. 

Change of air, scene, and occupation afford marked benefit in some 
cases, and, upon the whole, except in very chronic cases, a bracing 
sea air or sea voyage is not to be recommended without serious mis- 
giving. 

Internal treatment may be summed up by saying that the object of 
medicinal interference should be to correct any abnormal conditions 
present in the organs or secretions. Thus dyspepsia, or acidity, 
should be counteracted by appropriate remedies, and constipation by 
laxatives or purgatives. The use of these latter in chronic eczema, is 
universally acknowledged. Salines are especially valuable. Fried- 
richshall, ,Carlsbad, Pullna, Hunyadi Janos waters, or Rochelle or 
Epsom salt may be used. There is no better saline than the " white 
mixture" given early in the morning while fasting, so as to produce 
one or two copious motions of watery consistence. 

R. — Magnesii sulphatis ^ij. 

Vini colchici 3Jss. 

Magnesii carbonatis . . . . . ^ iij . 

Aquse menthse pip. ..... ad ^xij. — M. 

S. — Take a wineglassful early every morning. 

Another favorite saline combination in these cases in a mixture of — 



B . — Magnesii sulphatis 
Ferri sulphatis 
Acid, sulphurici dil. 
Aquse dest. 



• I ijss. 
. 3ss. 

• 3 ijss. 

ad ^xvj. — M. 



S. — A large wineglassful to be taken in half a tumblerful of water every 
second morning, and to be repeated in three hours if the bowels be not well 
moved. 

The saline should be occasionally preceded by a good dose of blue 
mass given at bed-time. It is manifest that this purgative treatment 
cannot be pursued for long periods without serious drawbacks. In the 
intervals the bowels will likely become very obstinate, and cascara or 
aloes,' in properly regulated doses, as mentioned under Constipation 
(page 144), should be employed. 

Where the tongue remains furred and appetite bad, especially where 



ECZEMA. 225 

there is a dry skin and scanty urine, an effervescing mixture contain- 
ing 1 ounce bicarbonate of potash and 1 drachm acetate of potash, 
dissolved in 10 ounces of water, may be given in doses of 1 ounce with 
2 ounce fresh lemon juice three times a day, to be swallowed during 
effervescence. 

Where eczema is associated with ansemia there is no iron prepara- 
tion better than Blaud's pill. 

In chronic cases associated with enlarged veins and a weak heart or 
diseased mitral valve, the eczema of the lower extremities is much 
improved by a combination of iron and digitalis. 

Internal remedies may be called for to allay itching and sleepless- 
ness. Opium, morphine, or chloral should not be used for this pur- 
pose. Sulphonal, in 20 grain doses, may be tried, but large doses of 
the bromide of sodium (30 grains) allay restlessness, without produc- 
ing any untoward results. 

Pye-Smith strongly recommends chloral in the eczema of children 
in order to insure sleep and prevent scratching. 

Gelsemium may be given alone or in combination, it sometimes 
allays itching in a marked degree (15 minim doses of the tincture). 
Belladonna or hyoscyamus in full doses may give sleep where opium 
cannot be given on accouut of its after effects upon the nerves of the 
skin. Quinine has the power of preventing itching in young subjects 
when given in full doses one hour before bed-time. Antipyrine is 
better, and acts when given in small doses (5 grains). 

Tartarized antimony certainly appears sometimes to have a modify- 
ing effect upon the course of eczema, especially in the more acute or 
subacute cases. Small doses only should be given, y 1 ^ grain in solution 
three or four times a day may be given for ten days. 

Hypophosphites, phosphates, malt preparations, cod-liver oil, chaly- 
beates of every kind, iodides, chlorate of potassium, iris versicolor, 
lithium, viola tricolor, rhus toxicodendron, tar, sulphide of calcium, 
turpentine, copaiba, guaiacum, and scores of other drugs have been 
vaunted from time to time as specifics for eczema when administered 
by the mouth. 

Arsenic is, however, a drug about the value of which there is no 
doubt in chronic eczema, and it is indeed the only drug which in our 
present knowledge can be said to constantly modify the diseased action 
in this troublesome ailment. 

It may be stated, as a rule, that arsenic is of value in proportion to 
the chronicity and dry or scaly state of the eczema, and it is almost 
equally true that it is, or may be injurious in the acute stage. One 
might safely tell the student that the nearer a case of dry chronic 
eczema, with its scaly surface and thickened base, comes to resemble 
psoriasis, the more clearly does the internal use of arsenic become 
indicated. 

It should be given in full doses, and it will be found unnecessary to 
push it to the extent of producing the physiological action of the drug. 



226 ECZEMA. 

Beginning with 3 minim doses of Fowler's solution after each meal, in 
about a fortnight 10 minim doses may be reached. 

Iron in small doses may be combined with the Fowler's solution in 
many instances with advantage. Hutchinson regards eczema as a 
local disease, and he believes that arsenic rarely does good, and that it 
often irritates. 

Pilocarpine has been given hypodermically in cases where the skin 
has remained dry and harsh, and good results have been reported. 

Electricity, in the form of the continuous current, has been used 
with advantage in inveterate cases. 

The local treatment of eczema might easily be made to fill a volume 
larger than the present. Only the more important leading principles 
and chief details can be enumerated. There is no specific for eczema 
— no royal road to its successful treatment, though there are few dis- 
eased conditions so susceptible to improvement or permanent cure. 
The secret of success in treating eczema lies for the most part in the 
ability of the physician to use the proper remedy at the various stages 
of the disease. The class of agents so, valuable in the acute are worth- 
less in the very chronic stages, while remedies of unfailing power when 
used in the chronic cases are fraught with serious danger when applied 
at the earlier stages of acute cases. The physician who wishes to treat 
the protean forms of eczema with success must learn to be patient, 
ever remembering that in the majority of cases the progress towards 
recovery is a slow one, and having fixed firmly before him the prin- 
ciple upon which his treatment is based, he should be content to wait 
till his local remedy has had time to act, before its failure is accepted. 
The constant chopping and changing of applications from day to day 
is one of the great causes of failure in the management of chronic or 
acute eczema. 

The writer before he had realized the natural progress of the affec- 
tion through the hypersemic to the papular, vesicular, pustular, weep- 
ing, scabbing, and scaly stages, had much disappointment in the results 
of treatment. He can recall cases now which were progressing towards 
recovery when an unfortunate impatience tempted a change in the 
local remedy, and cause the disease to break out afresh and run through 
all its stages over again. Had the treatment only been continued for 
a few days or weeks longer in these cases, uninterrupted recovery 
would have been the result. 

Acute eczema calls for soothing and bland applications. If seen at 
the very early stage the treatment should consist in the free smearing 
over of the part with an inert oil or grease, to protect the irritated 
surface from the action of the atmosphere or from changes in tempera- 
ture. But it is useless to cover over the seat of disease with ointments 
until scabs or altered or dried secretions have been thoroughly removed. 
These must be removed by one good cleansing with soap and water, by 
poulticing, or by bathing. This application of soap and water should 
not be repeated, and the rule should be laid down that the parts 



ECZEMA. 



227 



affected with acute eczema should not be washed, soaped, or poulticed 
till convalescence is fully established. At a later stage, and during 
the progress of treatment, secretions may be easily removed by apply- 
ing olive oil freely upon absorbent wool and gently wiping the part 
clean. If soap must be used, an over-fatted basis soap should be 
selected. Everything that can cause irritation, such as the friction of 
the dress rubbing against the part, profuse sweating, alternations of 
temperature, exposure to the air, scratching, etc., must be guarded 
against. 

In the early acute stage the indication is, as just mentioned, to 
soothe, cover over the painful part, and to protect it from all external 
sources of irritation. For this purpose lotions, dusting powders, 
pastes, oils, or ointments may be applied, and it is difficult to lay down 
any fixed rule for the selection of these remedies. The writer seldom 
uses lotions at this stage, unless astringents are required. Lotions 
must be applied on lint, and should not be covered with oiled silk, as 
they soon become poultices if this be done. The lint should never be 
allowed to dry, but constant moistening with the lotion must be kept 
up. This is impossible at night ; ointments are consequently much 
more convenient, and the best for routine treatment is the unguentum 
zinci oxidi. It may be made of firmer consistence by the addition of 
more of the oxide or of the impure carbonate. The following is a 
good formula : 



Or, 



Be . — Unguent, zinci oxidi 
Zinci carb. prsecip. . 



R 



Jij.— M. 

3ij- 
3J--M. 



3J- 

£iv. 

3iij- 

Wxl. 

£jss.-M. 



-Unguent, aquae rosas . 
Zinci oxidi 
Zinci carb. praecip. . 

Or MacKintosh's formula may be used : 
R. — Zinci oxidi 

Bismuthi subnit. 
Glycerin i pur if. 
Acid, carbolici 
Vaselini albi . 

Powdered arrowroot, 1 drachm ; oxide or carbonate of bismuth, 1 
drachm ; cold cream, 1 ounce, makes a bland, soothing covering. 
Formulae might be given to any extent — the above meet most require- 
ments. The ointment should be freely smeared over the surface, which 
should be then covered with lint, or old linen upon which a layer of 
the ointment has been evenly spread. Pure olive, almond, or linseed 
oils, or any of these mixed with an equal quantity of lime-water, may 
be used. If secretion be profuse, after the mild ointment has been 
used for a few days an astringent should be added to it. Lead in some 
form is the best. 1 drachm of the strong liquor of the subacetate may 



228 ECZEMA. 

be added to each 1 ounce of zinc ointment. Hebra's diachylon oint- 
ment is a good one. 

It is in those cases of acute weeping eczema that lotions may be used 
for a time with advantage. The dilute subacetate solution is a favorite ; 
a few minims of laudanum may be added to each ounce. 

In acute eczema, with very profuse secretion, powdered starch, 
arrowroot, carbonate of lead, carbonate of zinc, carbonate of magnesia, 
powdered Fuller's earth, oxide of zinc, French chalk, bismuth oxide, 
subnitrate or subcarbonate, lycopodium, powdered rice, and talc, may 
be mixed in various proportions, according to the amount of astringent 
action required, the lead being the most active in this respect. 

Where itching is smart, camphor in fine powder should be added to 
the above in the proportion of about 10 grains to each ounce of powder. 

Pastes are becoming extensively used in the treatment of eczema. 
They possess the great advantage of absorbing the aqueous secretions 
of the skin, which are pent up under the ointments, and they leave a 
firm, powdery residue on the skin not easily removed by friction, thus 
fixing the active ingredient. 

Lassar's paste consists of 2 ounces of vaseline, 1 ounce of starch, 1 
ounce of oxide of zinc, and 40 grains of salicylic acid. With this 
paste he envelops the entire body of an infant suffering from acute 
eczema, after having previously washed it, and touched any bleeding 
spots with a solution of caustic. The face, head, and joints are smeared 
over with a 2 per cent, ointment of salicylic acid in vaseline, and 
muslin bandages are firmly applied. 

Unna makes a paste by adding a small quantity of silica to zinc 
ointment. Bulkley adds to the zinc ointment a small quantity of 
ichthyol and salicylic acid, and thus makes a very efficacious combina- 
tion. 

Lanolin, lard, or vaseline, may be used as the basis of a paste made 
with any of the previously mentioned powders. 

Glycerin in undiluted form should never be used in acute eczema. 
Unna's glycerin jelly consists of glycerin, 25 parts ; water, 45 parts ; 
gelatin, 15 parts ; and oxide of zinc, 15 parts ; to which any ingredient 
may be added. Unna allays the burning itch of acute dry eczema by 
painting on this paste, warm, with a camel's-hair pencil. 

Should the acute eczema not resolve within a short time under the 
above treatment, more stimulating measures will be called for, and it 
may clinically be regarded as a case of sub acute or chronic eczema, 
and treated accordingly. 

Chronic Eczema. — If the affection has failed to respond to the 
soothing treatment, or if it has existed for a considerable period before 
coming under observation, applications of a more stimulating nature 
are demanded. The list of local remedies for chronic eczema seem3 
almost without end. The old drugs, which have stood the test for ages, 
are, after all, better, more certain, and more lasting than their modern 
rivals. Thus tar, mercurials, and lead will cope, if skilfully handled, 



ECZEMA. 229 

with most chronic forms of the disease. Upon the whole, ointments 
will be found more convenient and efficacious than lotions, though 
these latter are indicated under special circumstances. If there be 
very much exudation or moisture, the greasy nature of the ointment 
keeps the secretion in contact with the irritated surface. In some cases 
this is a serious drawback, and the discharge is, of itself, an irritant, 
and prolongs the mischief. In these cases a lotion containing an 
astringent must be used to check secretion. After an appreciable effect 
has been obtained in this direction, a stimulant like tar can be com- 
bined with the astringent lotion. The amount of stimulating ingre- 
dient must be small at first, and gradually increased, the physician 
cautiously feeling his way before employing strong remedies. 

A tar preparation which may soothe and quickly heal an itchy, dry 
eczema, associated with much infiltration, may act like fuel to the fire 
when applied to a moist, weeping, red eczema. It is a good rule, with 
chronic, weeping eczemas of this kind, to begin with lead lotions con- 
taining a sedative to allay itching and heat ; afterward tar can be 
safely used. 

The strong liquor plumbi in water (1 : 40), to which a \ part of 
laudanum or camphorated spirit is added, soon allays itching and 
diminishes secretion, but the number of cases in which an astringent 
ointment cannot be used instead is small. Liquor carbonis deterg. may 
be added to the above lotion with advantage (1 : 80). 

One of the best ointments ever used in chronic eczema is the follow- 
ing. It is astonishing to find the number of cases in which it can be 
used advantageously. The proportions of the different ingredients 
may be altered to suit the symptoms or peculiarities of each case. 

R . — Liq. carbonis deterg. ...... gj 

Hydrarg. amnion gr. x. 

Lanolini ^j. — M. 

If much secretion be present, 1 drachm of liquor plumbi may be 
added. Should there be dryness instead, with scaliness, the tarry 
ingredient may be safely doubled in amount, while the mercurial may 
be equally increased. 

Oil of cade, oil of white birch, creasote, carbolic acid, beta-naphthol, 
or naphthalin may be used instead of the liquor carbonis, which is a 
saturated solution of coal-tar in rectified spirit. The U. S. P. ointment 
of pix liquida is a good application, but should not be applied to hairy 
regions. It may be diluted with 1 to 4 parts of zinc ointment with 
advantage in most cases. 

The same rule which guides the student in selecting arsenic in the 
treatment of chronic eczema applies equally to tar and its preparations 
— i. e., the nearer the case appears to approach to psoriasis, the better 
will tarry compounds act. 

The cases of chronic eczema where tar is unsuitable are very few, 



230 ECZEMA. 

and, as a rule, it may be said that where tar fails it is because it has 
been used in a too concentrated form. Hutchinson regards tar as the 
one remedy for eczema. If he uses two, they are tar and lead ; if 
three, tar, lead, and mercury. 

Pastes, as mentioned under acute eczema, are equally valuable when 
employed in the treatment of the chronic affection. 

Lassar's paste may be used as the vehicle for any of the above- 
mentioned more active remedies. 

Unna uses ichthyol, 10 or 20 per cent., or sulphoichthyolate of am- 
monia, 2 per cent , which may be incorporated with the paste. 

Pick now treats the moist stages of all eczemas by his salicylic soap 
plaster, the formula for which is 5 parts of salicylic acid to 100 parts 
of liquefied soap plaster. When a weaker and more adhesive plaster 
is required, he mixes 2 i parts of the acid with 20 of olive oil and 80 
of soap plaster. These are spread upon strong calico, cut into strips, 
and firmly applied to the moist surface, where they may be allowed to 
remain undisturbed for several days. The itchiness is replaced by a 
burning pain, which rapidly disappears. Four days suffice for the first 
application before removal. Subsequent dressings may remain one 
week each. Sometimes three weeks may be allowed to pass without 
change of the dressings. 

When the scaly or dry stage is reached, the treatment by the sub- 
limate gelatin is indicated. This elegant, transparent, and elastic 
dressing is prepared by dissolving 30 parts of pure white gelatin in 
water over a water-bath, and evaporating the liquid solution till its 
weight is reduced to 75 parts ; 25 parts of glycerin and .05 bichloride 
of mercury are then added. This is simply painted on after the plaster 
has been removed, and it can be allowed to remain for days. 

Mercurials come in, in chronic eczema, in those cases where the use 
of strong, tarry preparations is doubtful — i. e., in subacute cases, where 
there is not yet much induration, and where redness and irritability 
lead the physician to doubt the wisdom of using tar ; or they may be 
combined with tar to great advantage. They should not be employed 
where a very large surface is affected. A dilute solution of the bi- 
chloride (1 grain to 2 ounces of water) is an excellent alterative, and 
may be used with great advantage as a lotion where crusts, scabs, and 
dried secretion cover over and irritate the already inflamed surface. 
But perhaps the best of all the mercurial preparations is an ointment 
of the white precipitate (of the strength of about 20 to 30 grains per 
ounce). 

Calomel, in similar proportions, often acts well. The dilute citrine 
ointment (1 : 8) is sometimes very valuable. These mercurials may be 
combined with zinc, lead, tar, or other remedies. 

The unguentum metallorum, containing zinc, mercury, and lead, is 
a favorite with many skin specialists. It may be made by mixing 
equal quantities of the B. P. ointments of benzoated zinc, acetate of 
lead, and citrine ointment. 



ECZEMA. 231 

In very chronic profusely secreting eczemas, great relief and im- 
provement have been obtained by painting over the weeping surface 
with a solution of silver nitrate (30 grains to 1 ounce). 

For very chronic dry eczema, painting over the patches with blister- 
ing liquid or liquor potassse sometimes gives good results, and Morris 
uses papain in some cases where there is great induration. 

Lustgarten uses the following combination for eczema of the anus 
and genitals : oleate of cocaine, 2 parts ; lanolin, 40 parts ; olive oil, 
10 parts, applied twice a day, followed by some absorbent dusting 
powder. 

Sulphur, in the form of ointment (1 drachm to 1 ounce), may be 
tried in very chronic dry cases, or pyrogallic acid (? drachm to 1 
ounce), chrysophanic acid (15 grains to 1 ounce), glycerin of tannin, 
alcoholic solution of soft soap, boric or salicylic acids, alkaline lotions, 
eucalyptol, thymol, or chloral (15 grains to 1 ounce), glycerin of borax, 
or alum, resorcin (1 drachm to 1 ounce), iodol, or iodoform (10 grains 
to 1 ounce). 

Papain and pancreatic emulsion are recommended for the removal 
of thickened epidermis, and salicylic acid, dissolved in collodion, may 
be used for the same purpose before applying any of the astringent 
ointments. 

Unna, in seborrhoeic eczema, uses resorcin. He states that there is 
no stage, no region, no age, no skin, nor any complication in which 
this drug may not be used, save in those rare cases of resorcin idiosyn- 
crasy. He gets the best results from a solution of 10 parts of resorcin 
and 10 parts of glycerin in 180 of strong spirits. Thin layers of cotton 
wool are soaked in a mixture of 1 part of this solution with 4 of water, 
laid upon the part, and covered with oiled silk. The horny layer swells, 
and the resorcin must be stopped, and greasy ointments applied, till 
cure results. Thickening and induration of the skin rapidly yields to 
resorcin when employed in this manner. 

Hans Hebra has recently introduced, under the name of glycerinum 
saponatum, a very elegant basis for ointments, and one which can be 
employed in chronic or acute eczema with advantage. It is a combi- 
nation of glycerin with an absolutely neutral cocoanut oil acid soap. 
It is made of two strengths. One contains 80 per cent, of glycerin and 
20 of the soap basis, the other contains 92 per cent, of glycerin and 8 
of the soap. Numerous combinations of this substance, with active 
skin remedies, are made. One of the most valuable is the zinc oxide 
glycerinum saponatum with amylum. It is useful in both acute and 
chronic eczema, and consists of 78 parts of the 92 per cent, glycerinum 
saponatum, 20 parts of zinc oxide, and 2 of powdered starch. The 
reader will get full descriptions of other useful combinations in the 
Edinburgh Journal, September, 1890. 

The above are but a sample of the interminable host of eczema reme- 
dies, but the physician who selects the older remedial agents, as lead, 
mercury, tar, and zinc, will be surprised to find how seldom he will fail 



232 ELEPHANTIASIS. 

to cure with them, and how seldom he will have to seek the newer 
drugs for the relief of the commoner symptoms or complications. 

The Martin's rubber bandage may be used with great advantage in 
the treatment of chronic eczema of the lower extremities, which so fre- 
quently is found associated with a varicose condition of the superficial 
veins. 

A careful adherence to the details already mentioned will enable the 
student to treat eczema upon whatever part of the body it may be 
located, without a special description of the treatment of each of the 
so-called special varieties. 

ELEPHANTIASIS. 

During the febrile attacks which come on at the different stages of 
this affection, the treatment will be that indicated in ague. Antipy- 
retics, like quinine, antifebrin, boiled fresh lemons, arsenic, iodine, and 
diaphoretics with mild saline purges. The local remedies are very 
uncertain in their action. The best appears to be the mercurial bin- 
iodide, made as an ointment and rubbed well into the hypertrophied 
tissue. It should be used of such strength as will not cause marked 
skin irritation, and where the situation of the tumor permits of firm 
continuous pressure being applied some form of elastic bandage may 
be used, and the affected parts placed in a position of absolute rest. 
At the same time they should be so elevated as to insure free circula- 
tion. Massage has been found useful in a few cases in the early stage. 

The above measures will cause the disappearance of the disease in 
some cases, provided the patient is at once removed from the locality 
where the affection was contracted. 

In advanced forms of elephantiasis, accompanied with great hyper- 
trophy, these remedies are ineffectual. Blistering, electricity, mercu- 
rial inunctions, digital compression of the main arteries, and even 
ligatures of the chief bloodvessels, though sometimes followed by great 
improvement are generally powerless to remove the hypertrophied 
tissue. If the leg be the part affected these means may be continued 
for a long time, and by their use combined with the continuous applica- 
tion of the elastic or India-rubber bandage, amputation may be avoided. 

Where the scrotum is affected the only satisfactory method of deal- 
ing with the tumor is to dissect out the penis and testicles with the 
spermatic cords, and remove the entire tumor with the knife without 
attempting to form any flaps. 

Tumors, weighing as much as a hundred- weight, have been thus 
removed, and the patient after a few months has been completely 
restored to health. By the skilful employment of numerous good 
assistants and the judicious use of Esmarch's bandage, the operation 
may be rendered as safe as an ordinary amputation and almost blood- 
less. 

In some desperate cases penis and testicles must be sacrificed by dis- 
secting out the patient from the enormous tissue. 



EMPHYSEMA OF THE LUNG. 233 

EMPHYSEMA OF THE LUNG. 

The treatment of this affection in the first instance will mean the 
treatment of the disease which has produced the emphysema. Bron- 
chitis, acute or chronic, pertussis, asthma, and other diseased conditions 
of the pulmonary organs associated with prolonged or violent expira- 
tory efforts of coughing are the direct cause of the complaint whose 
management is now under consideration. 

It will, therefore, be for the most part useless to think of removing 
the emphysema in the presence of a chronic bronchitis. In the treat- 
ment of chronic bronchial catarrh, with this object in view, remedies 
which render the sputum more liquid and less adhesive should have 
the first place ; secondly, remedies should, if possible, be used at the 
same time with a view to prevent all unnecessary coughing. 

Thus in the various forms of dry bronchial catarrh, especially in the 
variety observed in those whose occupations compel them to breathe 
air charged with fine dust, the incessant attempts at the expulsion of 
the irritating particles lead to the establishment of pulmonary emphy- 
sema of a severe type. The cough remains after the patient has ceased 
to breathe the irritating atmosphere, and it is out of proportion to the 
amount of bronchial inflammation present. The use of a stimulating 
expectorant, like iodide of potassium or apomorphine, combined with 
morphine, is of the greatest service in such cases. The treatment of 
the various forms of bronchitis is already mentioned under bronchitis 
(see page 82) and need not. be again enumerated. 

Very often the physician will meet with patients whose lungs are 
much involved with emphysema ; nevertheless they suffer no incon- 
venience except when laboring under at attack of bronchial catarrh. 
It such cases the greatest relief follows the judicious use of expectorant 
medicines. 

The question, however, of great importance is whether anything can 
be done to remedy the emphysema in the intervals between the bron- 
chial attacks. There are very good grounds for regarding the starting- 
point of the lesion in the air vesicles as a degeneration. This being 
so, remedies which will have a contra effect will of necessity be of the 
greatest service. Foremost among these will be improved hygienic 
conditions and everything that will tend to raise the standard of 
health. 

The excretory organs must be stimulated by gentle purgatives and 
active open-air exercise. The digestive functions should be improved 
when possible by attention to diet and tonics. The condition of the 
blood may be altered for the better by a course of arsenic or iron, or 
both. Arsenic is undoubtedly the best drug which we possess for the 
treatment of emphysema. It must, however, be given for a long time 
with great regularity, and the dose need not be large in order to obtain 
the best results — 2 or 3 minim doses of Fowler's solution with each 
meal. 

Next to arsenic will come cod-liver oil and iodides. The iodide of 

16 



234 EMPHYSEMA OF THE LUJSTG. 

potassium has the great advantage of being one of the most valuable 
of expectorants and anti- asthmatics, and at the same time it acts as an 
alterative, and stimulates the entire glandular system. It may be given 
at the same period as the previously mentioned remedies, or in courses of 
a few weeks' duration, and alternating with them. Hypophosphites are 
also very valuable. 

Various remedies are recommended for the breathlessness, but as a 
rule only those are of value which act upon the bronchial irritation 
nearly always present. Thus of inhalations, oxygen, terebene, spray 
of vin. ipecac, turpentine, eucalyptus, iodide of ethyl, and the whole 
army of expectorant medicines internally, especially grindelia, have 
been tried. 

Depressing expectorants are injurious in the majority of instances, 
as they interfere with the appetite, and may seriously tell upon the 
dilated heart, with its thinned walls. Their use should be occasionally 
suspended during the treatment of the chronic bronchitis present. 

Attempts have been made, from time to time, to treat emphysema 
independent of the affections from which it has arisen, and the treat- 
ment by compressed air has been followed with satisfactory results in 
some cases. This is carried out in various ways : 

1. The patient is made to inspire condensed air and to expire into 
into rarefied air. The pressure exceeds the ordinary atmosphere by 
about -g^. The inspiration of the compressed air causes more oxygen 
to enter the alveoli, while the expiration into rarefied air (^ less 
pressure than ordinary) causes more carbonic acid and residual air to 
leave the air vesicles. There is therefore an unusually brisk and com- 
plete exchange of gases and an increase in the respiratory movements, 
which it is affirmed produces or leads to increased elasticity in the 
pulmonary tissue. The treatment must extend over several weeks. 

2. It is found in practice to be much more satisfactory to cause the 
patient to sit and breathe for a couple of hours daily in a chamber, the 
atmosphere of which has been gradually compressed to the extent of 
about J of an additional atmospheric pressure. 

This atmospheric chamber or compressed-air bath in a short time 
(according to Williams) causes the patient to breathe much easier, 
deeper, and slower. As the cardiac and hepatic dulness increase, the 
true vesicular murmur reappears. The vital capacity increases, while 
the circumference of the thorax diminishes. An air bath of this kind 
every other day for two months is generally considered sufficient. The 
general nutrition of the body improves, and digestion is quickened and 
appetite augmented. 

A mixture of carbonic acid gas and pure oxygen (1 : 4) has been 
given as an inhalation (about 40 gallons per diem) with the same 
objects, but the results are far from satisfactory. The same remark 
applies to inhalations of oxygen and ozone. 

In advanced cases of the disease the heart is generally dilated to a 
considerable extent, and the cardiac tonics — strophanthus, digitalis, 



EMPHYSEMA (GENEKAL) — EMPYEMA. 235 

sparteine, strychnine, and caffeine — always afford some relief. A dry 
climate is the best, but high altitudes are generally not to be recom- 
mended. 

EMPHYSEMA (General). 

The extravasation of the air into the cellular tissue of the body 
seldom calls for active interference. Unless the accumulation of air 
becomes so extensive as to jeopardize life by embarrassing the action 
of vital organs, the case had better be left alone, as absorption always 
takes place spontaneously. Bandaging of the entire body from the 
toes to the chin has been successful in a few cases. Should suffocation 
threaten, the skin may be tapped by a Southey's trocar and canula in 
several places at once, or several incisions may be made by an abscess 
knife. 

EMPYEMA. 

As soon as the presence of pus is demonstrated in the pleura by 
the hypodermic syringe, aspirator, or exploratory trocar or grooved 
needle, no time should be lost in securing its removal. Delay means 
danger for several reasons, chiefly on account of the risk of the lung 
becoming so fixed and bound down by adhesions that expansion may 
never occur. 

From the success ia a very limited number of cases which has been 
known to follow the removal of the purulent fluid, the physician will 
be justified in first trying the effects of drawing off the pus by any of 
the ordinary methods before he resorts to free incision or resection of 
ribs. 

The usual site in the axillary line about the fifth or sixth space may 
be selected, unless some intercostal space reveals marked bulging below 
or behind this region, when it may be selected. A trocar and canula, 
or any of the numerous forms of aspirators, may be used. A very 
convenient form of instrument is a canula, to which a fine India-rubber 
tube is attached through the intervention of a short branch near its 
collar. The trocar of this apparatus works in the canula like a 
piston-rod, and after both have been inserted into the pleural cavity, 
the trocar is withdrawn so that its point clears the opening into the 
branch of the canula to which the tubing is attached. The branch is 
furnished with a stop-cock. If the free end of the tubing (which 
should be about six feet in length) be dipped into some antiseptic fluid 
in the bottom of a basin placed under the patient's bed, and the stop- 
cock be now turned on, the purulent contents of the pleural cavity 
may be syphoned into the basin without any risk of air being admitted 
into the chest. 

As much fluid may be removed as will flow spontaneously through 
the tube without causing symptoms of cough, dyspnoea, or faintness. 



236 EMPYEMA. 

Should such embarrassments arise the stop-cock may be closed for a 
time, and they will generally pass off. 

The instrument is so made that the trocar cannot be completely 
withdrawn from the canula, and it possesses this great advantage that 
when the latter is blocked up by clots or plugs of fibrin its lumen can 
be easily cleared by simply pushing back or driving home the trocar, 
and pulling it forward again. 

The instrument should be thoroughly rendered aseptic by immersion 
in carbolic, or weak bichloride of mercury solution. The patient may 
lie in bed with the shoulders well proped up by pillows. * 

Aspiration may be resorted to, but it is not safe to use the hollow 
needles in tapping the chest, their sharp points are liable to puncture 
the lung. When the aspirator trocar is withdrawn from its canula, 
the end of the mouth attached to the rubber tube should be rapidly 
inserted into the extremity of the canula, and the admission of air 
avoided ; this should be done during an expiratory movement. 

In using Dieulafoy's instrument in the ordinary way the negative 
pressure or suction force is very unequal at different stages of the tap- 
ping. When the piston is drawn to the very top of the cylinder, and 
the vacuum thus created is suddenly brought into connection with the 
column of fluid in the canula by the turning on of the stop-cock, the 
difference of pressures is so great as to suck shreds of fibrin into the 
canula which may block it up. The jerky way in which the fluid is 
thus pumped out is, moreover, liable to bring on paroxysms of cough- 
ing or dyspnoea. The writer after the first complete exhaustion of the 
cylinder (which should always be made prior to the insertion of the 
trocar and canula) finds it much better afterward to draw slowly up 
the piston as the fluid gradually flows into the cylinder. In this way 
a much more equable negative pressure is maintained than by the ordi- 
nary method of alternately making a complete vacuum, and causing a 
sudden rush of fluid with great force into the cylinder. 

As much pus should be drawn off as can be got away without caus- 
ing serious embarrassment, and the opening should be carefully closed 
with a pad of carbolic lint secured by strapping. 

The method of treating empyema carried out by Biilau is safe, sim- 
ple, and satisfactory as far as results go. He inserts a wide trocar 
and canula between two of the lower ribs, withdraws the trocar, and 
passes into the pleural cavity, through the canula, a full-sized rubber 
drainage-tube. This is fastened in situ, and connected by a bit of glass 
tubing with several feet of rubber tubing which is dropped into a ves- 
sel containing sublimate solution. As soon as the drainage-tube is 
lodged well into the pleural cavity, the canula is pulled over it and 
removed, and nothing left but the tubing. The contents are slowly 
and painlessly syphoned off without the danger of the admission of air, 
or the risk of pulmonary embarrassment being created. 

Generally in a short time signs of reaccumulation show themselves, 
and in the absence of urgent symptoms the physician may try a second 



EMPYEMA. 237 

tapping with the hope that the pus may not return. Though this hope 
must have little grounds in the case of adults, nevertheless in the case 
of children a complete cure sometimes follows the second tapping. 
When the fluid collects after the second aspiration a free incision must 
be determined upon. 

If there be any evidence of " pointing," the site of the opening will 
be the point at which the bulging is most prominent. Marshall has 
shown that this is most frequently in the fifth interspace in front, ex- 
ternal to the cartilages — a spot in which it is found that the thoracic 
parieties are the least protected ; and this surgeon advises the opening 
to be made here whether pointing has occurred or not. 

There is much difference of opinion among surgeons about the 
most suitable site for incision, and the matter is not of vital moment. 
The incision may be made in the sixth or seventh space in the axillary 
line, or in the eighth, ninth, or tenth space behind in the line of the 
angle of the scapula. 

The most dependent part of the pleural sac will be the best to secure 
thorough drainage, but the lowest part of the sac may be already sealed 
up by the pleuritic inflammation, and should the surgeon make an in- 
cision into the tenth or eleventh intercostal space as advised by some 
he may find it impossible to enter the pleural sac. 

Upon the whole the following will be found the most judicious line 
of action. The patient being under chloroform is placed upon his 
back, and very slightly rolled over upon the sound side. 

Under the antiseptic spray an opening may be made in the sixth or 
seventh space large enough to admit a sound, which after its introduc- 
tion is moved downward and backward until the posterior and lower 
limits of the pleural cavity are determined. At the most depending point 
of the sac the extremity of the sound is made to bulge out an intercostal 
space, over this the surgeon makes a clean, free incision a couple of 
inches in length into the pleural cavity, going through the thickened 
pleura close to the upper margin of the lower of the two ribs bounding 
the selected intercostal space so as to avoid the intercostal artery run- 
ning along the lower margin of the uppermost rib. The centre of the 
incision may with advantage fall behind the line of the angle of the 
scapula. If it be found that the ribs are so close together as to leave 
too little room for the free exit of matter, the surgeon proceeds to 
remove a portion of the adjoining rib. 

After the removal of the periosteum from the external surface for 
about two inches by a periosteum-elevator, this instrument is then in- 
sinuated between the bone and the periosteum on the internal aspect 
of the rib, and the rib is divided in two places by forceps or saw or 
chisel, and about one and one-half to two inches taken away. This 
will leave an aperture of sufficient magnitude for the free drainage of 
the cavity. The subsequent management of the case will vary accord- 
ing to circumstances. 



238 EMPYEMA. 

Fagge in the case of children inserted the end of a fine rubber tube 
into the opening which he made so small as to cause the tube to be 
firmly grasped by the skin, the other end of this tube he carried be- 
neath the surface of some carbolized liquid in a jar placed beneath the 
bed. The negative pressure of the column of liquid acting hydro- 
statically he found to gradually cause expansion of the compressed 
lung, and rapid cure often resulted. The results were identical with 
those obtained by the less formidable method of Biilau just mentioned. 

When the second opening has been made as above described, and 
the pus evacuated, the upper opening is carefully closed. To insure 
thorough drainage and to keep the lower opening patent a stout drain- 
age-tube is inserted, this tube should have a flange to prevent its slip- 
ping inside the cavity and being lost. Tubes are made of rubber, 
vulcanite, metal, or celluloid, and should be held in position by a large 
pad of carbolized tow or oakum. They may be removed and cleansed 
as often as required. 

W. Williams has devised a valvular tube for removing the atmos- 
pheric pressure from the external surface of the lung while the chest- 
wall opening remains patent ; this facilitates the expansion of the lungs, 
and is a distinct gain if experience proves that it can be easily worked. 

Where the contents of the cavity become putrid, weak injections of 
Condy's fluid, carbolic or boric acids, bichloride of mercury, iodine, 
chlorine solution, quinine, or other antiseptics may be used. The sud- 
den deaths that have followed the use of the mildest of these injections 
should make one pause before resorting to their use, and innumerable 
successes without irrigation show that ordinarily the washing out is not 
essential. 

If the above treatment fails to relieve, and the pleural cavity con- 
tinues to secret pus for months, and it becomes evident that delay in 
healing is owing to the failure of the lung to expand and the inability 
of the chest- wall to fall in and obliterate the space because of rigidity 
of the ribs, there is nothing open for the surgeon but to perform 
Estlander's operation and excise portions of several ribs. As much as 
four inches of the third, fourth, fifth, and sixth ribs with the thickened 
pleura attached to them may be removed, and the chest-wall permitted 
to fall in and obliterate the cavity, after which a cure may be expected. 

It is hardly necessary to say that during this slow-healing process 
there must be the closest attention to the general health of the patient. 
Everything that improves nutrition, appetite, digestion, sleep, cough, 
etc., must be from time to time pressed into the service. Change of 
air, scene, and climate may be demanded. 

Attention should be paid to the position of the patient's body, so as 
to secure the most thorough drainage ; and at first he should be made 
to lie upon the affected side, so as to ensure that the opening will 
correspond to the most'"dependent point. 



ENDOCARDITIS. 239 

ENDOCARDITIS. 

The treatment of this affection, which is so frequently a complication 
of acute rheumatism, is to a large extent also the treatment of the 
rheumatism. In the early stages of the fever much can be done to 
prevent the development of serious endocardial inflammation. Sibson 
pointed out the enormous importance of absolute rest. A study of the 
clinical reports of patients so treated showed that endocarditis occurred 
almost though not quite so frequently among them as those treated 
without rest. But it also showed that though endocarditis supervened, 
it was much less likely to be followed by permanent valvular mischief 
in those subjected to a thorough rest treatment. 

These facts proves the great importance of ordering the rheumatic 
patient immediately to bed as soon as the symptoms of fever and joint 
trouble declare themselves. 

Conflicting opinions prevail about the value of salicin or salicylates 
in preventing endocarditis. The writer has carefully watched the re- 
sults of this treatment at the bedside, and has, as far as possible, kept 
an eye upon the patients afterward. His experience, though it does 
not lead him to believe that the salicylic acid treatment more than 
appreciably lessens the chance of endocarditis, nevertheless leads him 
to believe that it will be proved that a large proportion of the salicylic 
cases escape the more serious forms of valvular lesion. 

The impurities so constantly found in the artificial acid may possibly 
tell against the results. (See under Eheumatism, Acute.) 

Every means that will lessen cardiac activity and relieve pain must 
have some beneficial action in lessening the risks of cardiac complica- 
tions, and must have some modifying action upon these complications 
when already established. ' 

When the physical signs indicate that endocarditis has already 
supervened, the salicylic treatment, according to the great majority of 
observers, should be discontinued. The writer has, however, continued 
its administration in full doses where the pain and fever kept high. 
Recently-acquired knowledge will, however, lead him always to employ 
the natural or repurified acid under such circumstances. 

In the absence of pain and fever, the salicylic treatment should 
always be stopped. Absolute rest must be still enforced, and the 
patient should not be permitted to even sit upright in bed. The nurse 
must insist upon the use of the bed-pan on all occasions. 

In place of the salicylates the best treatment now is full doses of 
alkalies combined with opium. 20 grains of bicarbonate of potash, 
with 5 minims of laudanum, may be given every four hours. Should 
this line of treatment be pursued for any length of time, it will be well 
to substitute the sodium for the potassium salt, owing to the depressing 
effect of the latter upon the cardiac muscle. Quinine in large doses 
may be given when the temperature keeps high. At a later stage 
stimulants may be demanded. Should the case become grave, alcohol, 
ammonia, and digitalis may be given in combination, but only when 



240 ENDOCARDITIS. 

there is evidence of failure of the ventricle. Harm is decidedly done 
by the haphazard employment of large doses of digitalis the moment 
that any cardiac lesion is discovered. Moreover, it is of little use if 
the temperature is high. Karely will the embarrassed condition of the 
right ventricle call for venesection, though the writer has seen marked 
relief follow the administration of a smart saline purgative in endo- 
carditis. Aconite in small doses in the early stage is recommended, 
but it should be discontinued as soon as the pulse falls. 

Local applications are of value in endocarditis when precordial pain 
and distress are prominent. The application of a linseed poultice, 
upon which a little unguentum belladonna is smeared, is an effective 
remedy. The extract, rubbed up with glycerin, may be smeared over 
the cardiac area. The liniment alone, or mixed with chloroform lini- 
ment, and covered with oiled silk, or the belladonna plaster may be 
applied. Leeches may in rare cases be called for. 

Often a small blister, kept in contact with the skin above the apex 
region for a period not exceeding three hours, gives relief to distress- 
ing sensations in this region, and quiets cardiac action if tumultuous. 
The writer has seen acute rheumatism" in its earliest stages treated by 
Dr. Harkin, who applies a large blister over the cardiac region (quite 
independent of the absence or presence of cardiac complications). The 
result of this treatment, as regards the prevention or occurrence of car- 
diac complications, will be of great value ; at present the number of 
cases is too small for basing any conclusions upon. The effect upon 
the heart, temperature, and pains, was always striking in those cases 
under the writer's notice. 

Dr. Sansom thinks that vesication, by applying the callodium cum 
cantharide over the skin of the left axilla, is of service in endocarditis. 

In the presence of symptoms suggestive of a thrombus having formed 
in the cardiac cavities, ammonia should be freely given in large doses 
by the mouth, and, if dyspnoea continue with serious symptoms, it may 
be given also by hypodermic injection. In the absence of urgency, 
grave symptoms may be combatted with the following combination of 
Bartholow's : 

R. — Ammonii carbonatis . . . . . ^ ij. 

Liq. ammon. acetat. ...... ^vj. — M. 

S. — A tablespoonful with a littie water every six hours. 

The after-treatment of endocarditis will be best carried out by a 
course of iodide of postassium in small doses, and, for a long time, rest 
must be enjoined. From what has been already said, it will be evident 
that an early return to active exercise or to busy life, will probably 
have a serious determining influence upon the nature and extent of the 
valvular lesion. Prolonged rest after apparent convalescence will give 
the patient the best possible chance of escaping without a permanent 
valve trouble. In the writer's experience, it is not rare to find systolic 
apex murmurs disappear at this period. 



ENDOMETRITIS. 241 

In ulcerative endocarditis, in addition to the above measures, hope 
of success seems to lie in the internal administration of large doses of 
antiseptics. Sansom strongly insists upon the continuous administra- 
tion of the sulphocarbolate of sodium, in 30 grain doses three times a 
day, and, at the same time inunctions of carbolized oil (1 : 5) over 
the chest and back, morning and evening. He believes that the soda 
salt appears in the tissues as sulphate, the phenol being set free 
rendering the tissues antiseptic. 

Success has followed the administration of large doses of quinine, 
and small doses of the bichloride of mercury. 

Stimulants and, at a later stage, large doses of iron preparations, 
especially the tincture of the chloride, will be indicated. 

ENDOMETRITIS. 

Rest, in the horizontal position, must be insisted upon in the acute 
form of the disease. If the attack is the result of any septic mischief, 
caused by retained placenta, the accompanying metritis and peritonitis 
often present will call for remedies to relieve pain and reduce fever. 
Should there be evidence of any retained membranes, clots, or secre- 
tions, the uterus should be well washed out with weak sublimate solu- 
tion. In the absence of such evidence, local injections in the early 
stages are mischievous. Poultices over the abdomen, or warm fomen- 
tations, should be constantly applied. The surface of the poultice may 
be smeared over with belladonna ointment. One large enema of tepid 
w T ater should be employed to thoroughly empty the rectum, after which 
the bowels should be let alone. Purgatives at the early stage of the 
affection do more harm than good. 

Pain should be relieved by morphine suppositories, and it is a good 
plan to give a little opium by the mouth at short intervals, say 2 grains 
of Dover's powder every two hours with J grain of quinine. A dozen 
leeches may be applied round the anus in very severe cases. 

After the more urgent symptoms have been combated by these 
means, hot sitz or hip baths may be frequently used. 

Vaginal injections of large quantities of hot water while the patient 
is in the bath, or afterward, are very beneficial as soon as leucorrhoeal 
discharge appears. Proper precautions must be taken to prevent the 
vaginal tube being passed into the uterine cavity. 

Continuous flow by a can and syphon arrangement is better than the 
intermittent jetting of the ordinary rubber suction apparatus. The 
temperature of the fluid should begin at about 102° F. and be gradu- 
ally raised to 108° F. About one gallon of fluid should be used at 
each sitting, and this may be repeated two or three times a day. A 
tablespoonful, or double this quantity, of pure carbolic acid may be 
thoroughly dissolved in the water. 

After the discharge has been established for some days, saline purga- 
tives are useful. If hemorrhage or menorrhagia appear, the best 
treatment will be hypodermic doses of ergotine. (See Metritis.) 



242 ENDOMETRITIS. 

In the treatment of the chronic form of the disease constitutional 
remedies hold a high position. There are few diseased conditions 
whose successful management entails such a severe tax upon the skill 
of the physician. 

Rest, except immediately after some operative interference, does 
more harm than good, but moderate rest should be advised during or 
about the end of menstruation, and during the early period of preg- 
nancy if the condition be not so advanced as to cause sterility. 

Every measure calculated to improve the general health and nutri- 
tion of the patient must be insisted upon. A most minute and search- 
ing examination should be made into the habits, family and previous 
history and general condition of the sufferer before this can be decided 
upon. Any violation of a health law must be set right before local 
treatment is thought of. Errors in diet, resting or taking of exercise, 
evacuating the bowels, etc., may be easily set right. Constipation 
must be promptly and perseveringly treated. (See Constipation.) 
Appetite, if failing, should be aided by mineral acids with quinine. 
Strumous, syphilitic, or other dyscrasise can be met by appropriate 
remedies and sexual excesses prohibited. 

A prolonged course of arsenic, iodide of potassium, or iron may be 
given with advantage after the more urgent or important symptoms 
have been combated, and these drugs can be given in short alternate 
courses with great benefit. 

During the management of the case the physician will find himself 
called upon to relieve symptoms, and to prescribe temporary remedies 
until opportunity offers to strike at the root of the disease. Pain must 
be relieved when severe, and this should be done when possible without 
resorting to narcotics. 

Hot water vaginal injections may be freely used, and these may be 
assisted by the hot sitz or hip bath. One or two gallons of water at a 
temperature of not less than 105° may be made to syphon continuously 
through the vagina, soothing local irritability aud influencing the en- 
tire pelvic circulation most beneficially. In the intervals between the 
use of hot injections bromides are of much value in diminishing local 
sensibility, and their use may be kept up where narcotics would be 
objectionable. The dilute hydrobromic acid combined with sodium 
bromide and a small dose of quinine, is a good routine method of 
relieving the distressing sensations so commonly observed during the 
course of chronic endometritis. 

For occasional use antipyrine (10 grains) or antifebrin (5 grains) 
often acts like a charm. 

Opium, morphine, chloral, codeine, belladonna, hyoscyamus, alcohol, 
cannabis indica, conium, and other sedatives or narcotics may from 
time to time in emergencies be employed, but in a disease whose nature 
and duration is so essentially chronic, the habitual use of any of these 
potent remedies is to be strongly condemned. The least objectionable 
of them is a combination of belladonna and codeine with or without 
Indian hemp : 



ENDOMETRITIS. 243 

R. — Ext. belladonna fol. . ... . . . gr. §. 

Ext. cannabis ind g r - 3- 

Codeine gr. §. — M. 

S. — One pill four times a day, if in severe pain. 

Any of the above may be given as a suppository or medicated 
pessary, and in this form are less objectionable than when adminis- 
tered by the mouth. 

Ed is recommends counter-irritation by a series of small blisters 
applied over the seat of pain, and relief may be often obtained by 
applying upon lint a mixture of equal parts of liniments of bella- 
donna, aconite, and chloroform under oiled silk. Plasters of bella- 
donna and opium may afford considerable comfort when worn over the 
back and loins, and over the lower part of the abdomen in front. 

Local treatment will consist in first setting right any complication 
that may be found to exist, flexion or version should be corrected by 
proper pessaries. Cervical endometritis, when present should be 
dealt with by removing all discharge, slitting up the os if narrowed, 
and applying caustics to the cervical canal by means of a Playfair's 
probe, armed with a layer of absorbent wool. 

Pure carbolic acid, iodized phenol (1 ounce iodine dissolved in 4 
ounces strong carbolic acid) solution of nitrate of mercury, or chloride 
of iron, stick of caustic (nitrate of silver), strong nitric acid, chromic 
acid, or other escharotic may be used for this purpose. Granular 
cervix may be treated in the same way. If there be much conges- 
tion, engorgement, or inflammation of the lower part of the uterus, a 
surprising relief often follows the insertion of a large plug of absorb- 
ent cotton wool saturated with pure glycerin, and allowed to remain in 
the vagina for twenty-four or forty-eight hours. 

Should the probe be found to pass easily up into the cavity of the 
uterus, and its lining membrane be found roughened and hypertro- 
phied, and especially if the endometritis has been known to follow 
abortion, or to have had its origin in retained placenta, the curette or 
Simpson's uterine scoop may be used. In this way, after drawing 
down the uterus with a vulseilum, the curette is made to scrape the 
uterine walls from above downward, beginning with the anterior. 
After the removal of the debris, a probe, well covered with wool and 
dipped in pure carbolic acid, iodized phenol, or any of the caustic 
solutions just mentioned, should be used to swab out the interior of 
the uterus. The curetting, followed by caustic applications, is, no 
doubt, heroic treatment, and it is seldom that it has to be resorted to. 
The great majority of cases, even of long standing, will be sufficiently 
well met by swabbing out of the uterine cavity by caustics without 
previous curetting. 

It is of great importance to remember that these operations should 
not be undertaken at a time close upon the menstrual period. The 
best^time k is^ about nine days after menstruation has ceased. As a 



244 EJSTTERITIS-ENTKOPION. 

rule, one application, or, at the most, two, should only be made to the 
interior of the uterus every month, and rest for several days in bed 
should be insisted upon after each operation. 

Many cases can be successfully treated by caustic applications con- 
fined to the cervical canal. 

Recently Duinontpallier has reported the treatment of 100 cases 
without accident, and with 96 successes, by inserting a pencil of 
chloride of zinc up to the fundus of the uterus, and then leaving in a 
vaginal tampon, the slough caused by the caustic coming away in 
about seven days. After-treatment consisted in antiseptic douching, 
until the final separation of the slough. 

Iodoform has been used successfully in the same way, and it is safer 
and more controllable. 

The practice of injecting caustic solutions into the uterine cavity, 
or of passing up solid caustics and ointments, and allowing them to 
remain there, should only be followed out under very exceptional cir- 
cumstance, and this treatment had better be left in the hands of 
specialists. Many deaths from peritonitis, caused by the injected 
matter travelling up the Fallopian tubes, have been recorded. In most 
instances, before swabbing out the uterus with caustics, it will be ad- 
visable to dilate the cervical canal rapidly, or by means of laminar ia 
tents. The writer has had excellent results after such dilatation, and 
the application of strong nitric acid to the uterine cavity, as recom- 
mended by Atthill. 

After the application of caustics in this way, it is advisable to insert 
a large vaginal tampon of wool soaked in glycerin, and administer 
^ grain of morphine as a suppository, aud to keep the patient at rest 
in bed for several days. The caustic applications may require repeti- 
tion at considerable intervals. 

The subsequent administration of ergot — 20 minims of the fluid 
extract, or 1 grain of ergotine, or 1 drachm of the fluid extract of 
ustilago maydis — will do much in restoring the uterus to its normal 
condition. (See Metritis.) 

ENTERIC FEVER— See Typhoid Fever. 

ENTERITIS. 

The treatment of this affection, which can hardly be regarded as 
existing as a primary disease, will correspond to the management of a 
case of acute diarrhoea or dysentery. (See under Diarrhoea and Dys- 
entery.) Where the condition is obviously secondary to some other 
affection, its treatment will be referred to under the head of the pri- 
mary affection. 

ENTROPION. 

Entropion, or inversion of the eyelids, and ectropion, or eversion of 
the lids, may be considered under the one heading for convenience. 



ENTROPION. 245 

If the ectropion, or eversion of the lids, be depending upon a hyper- 
trophied conjunctiva, the result of old inflammation, the excision of a 
longitudinal piece of the thickened membrane will bring the margin 
of the lid into its normal place. The solid stick of caustic, in mild 
cases, may also accomplish this. Any bands or adhesions of the skin 
to the margins of the orbit should be freely divided subcutaneously, 
after which it may be necessary to sew the lids together, until the 
healing process is complete, in order to prevent a recurrence of the 
eversion. 

Plastic operations, with transplantation of the skin, may be neces- 
sary in bad cases. If the ectropion be caused by paralysis of the 
seventh nerve, ending in the loss of power in the orbicularis, treatment 
by hypodermic injections of strychnine may be useful. The canali- 
culus may require to be split in order to remedy the lachrymal over- 
flow, and measures must be taken to prevent destructive inflammation 
of the exposed conjunctiva. 

Entropion seldom fails to return after temporary strapping back of 
the inverted lid, even when the affection is simply owing to spasm. 
The best procedure is to pinch up a fold of skin close to the margin of 
the lid and snip it out with scissors, making the removed portion pro- 
portionable to the degree of inversion. At the same time, a small 
fold of the exposed orbicularis muscle should also be removed, and 
the marginal fibres of the orbicularis, at the external angle, may also 
be cut through. The wound will heal without sutures. 

Where there is organic thickening, with much trichiasis, it will be 
necessary to dissect out a strip of tissue containing the lashes along 
the margin of the lid. This is done by splitting the lid in the first 
instance, and making an incision about one-twelfth of an inch from 
the margin of the lid, along its entire length. The strip removed 
should contain the cartilage and hair follicles. 

Biirow's operation consists in making an incision from the conjunc- 
tival surface along the entire length of the lid, and close to its margin. 

Arlt's operation is performed by deeply splitting the lid in its entire 
length, and removing a semicircular flap of skin along its margin, 
after which the edges of the wound are sutured. This tilts forward 
the margin of the lid containing the lashes. 

Other operators, as Streatfield and Wells, remove a wedge-shaped 
piece of the tarsal cartilage in order to secure more complete eversion 
of the margin of the lid. 

Van Milligen's operation consists in splitting the lid, by a free inci- 
sion in the intermarginal space, for its whole extent. The gap thus 
formed is kept open by sutures passed through the skin of the upper 
lid. A linear strip of mucous membrane is then dissected off the in- 
ternal aspect of the lower lid, and adjusted into the hiatus caused by 
the splitting incision. 

ENURESIS— See Incontinence of Urine. 



246 EPILEPSY. 

EPIDIDYMITIS— See Orchitis. 
EPILEPSY. 

The treatment of this affection will embrace the management of the 
patient (1) during an attack, (2) immediately before an attack, and 
(3) in the intervals between the attacks. 

If the physician should chance to see the patient when the seizure 
is taking place, he will find that, beyond attention to a few details, his 
position must be one of " masterly inactivity." 

The instant removal of all constrictions about the neck or throat 
should be seen to, and the patient should be placed flat upon his back 
if he has not already naturally assumed this position. A soft pillow 
may be placed under his head, and attention given to the state of his 
mouth. If the tongue protrudes, a large cork or piece of rubber 
tubing may be inserted between the teeth to prevent its being injured. 
Any artificial teeth or food should, if possible, be removed from the 
mouth. 

It is useless to make attempts to restrain the movements by forcibly 
holding down the convulsed limbs ; all that can be done is to watch 
and see that the patient inflicts no injury upon himself during the 
clonic spasms. There are, however, some measures which may prove 
useful during a severe epileptic seizure. 

Pressure over the carotid artery upon each side, by thrusting the 
thumbs deeply against the skin at the root of the neck, and making 
firm pressure backward, compressing the tissues very firmly between 
the thumbs and the spine, often cuts short the attack. It was supposed 
that by so doing, the amount of blood going to the brain was suddenly 
lessened, but the effort produced upon the convulsions is more proba- 
bly caused by the influence of the pressure upon the cervical sympa- 
thetic, and vagus nerves. This manoeuvre is sometimes also tried to 
prevent an attack which is threatening. 

Inhalation of the vapor of nitrite of amyl often modifies the attack 
in a marked degree ; 5 minim capsules may be broken, and the vapor 
inhaled through the nose. This may be repeated every thirty minutes 
in those cases where the coma lasts long after the convulsions have 
ceased. 

The treatment in the intervals between the attacks has been very 
varied in the hands of different authorities, but there is no remedy 
equal in its effects to large doses of bromine salts. This should be 
the method employed first in every case of epilepsy, even where only 
one attack has taken place, as experience proves that the first fit of 
epilepsy, or of petit mat, the bromide should be given at once, and per- 
sistently continued for many months, if the seizures recur. The treat- 
ment may be continued with very short periods of rest, for years. If 
no second attack happens the patient may be permitted to leave off in 
twelve months, having previously from the end of the first six months 
limited himself to one large dose at bed-time. 



EPILEPSY 



247 



Different opinions prevail about the relative values of the different 
bromides. The potassium salt is the favorite, and may be given in 
doses of 20 to 30 grains three times a day after meals for a long time. 
The ammonium and sodium bromides may be given in similar doses. 
It is often to be found that the symptoms of bromism which supervene 
after the potassium salt has been given for some time may be caused to 
disappear or lessen by substituting the sodium preparation for a time. 
The potassium base has a very depressing effect upon the muscular and 
cardiac apparatus, and should not be ordered in large doses for indefi- 
nite periods. It will be found wise to discontinue the use of all bro- 
mides for a few days when severe headache, loss of appetite, great 
muscular weakness, malaise, and impairment of sensations in various 
regions appears. In returning to treatment again, the writer begins 
with the dilute hydrobromic acid in 30-minim doses, freely diluted, 
three times a day. It is a good plan to keep the patient for one 
month at a time upon 20 grains of a bromide salt, changing it to 
another at the end of this period. Thus, in turn, the bromide of potas- 
sium, bromide of sodium, bromide of ammonium, and hydrobromic 
acid may be administered for four months. It is a very difficult point 
to determine which one of these salts is the most valuable in any given 
case. The writer believes that he has seen better results from the 
bromide of ammonium when given in the cases of children and very 
young adults. Some authorities prefer the ammonium salt to the other 
bromides in petit mal. In nocturnal epilepsy one large dose should be 
given at bed-time. 

Brown-Sequard insists upon a mixture of the bromides as giving 
much better results than any one singly. The following is his 
favorite combination given before meals, while after meals a tonic is 
ordered consisting of either strychnine or arsenic with a vegetable 
bitter : 



R . — Potassii iodidi 


• • • 3ij- 


Potassii bromidi .... 


• • • I'y 


Ammonii bromidi .... 


. 3iij. 


Potassii bicarbonatis 


• • • 3J- 


Tinct. calumbse .... 


• • • 3j. 


Aquae destil 


• • • tt- 



-M. 

S. — A teaspoonful before meals three times a day, and three teaspoonfuls at 
bed-time, in water. 

Where petit mal is present, he advises the ammonium salt to be 
increased and the potassium salt diminished. The same authority 
states that patients have taken the above combination for eight or ten 
years without harm. 

There is no practical guide to fche amount of bromides which an 
epileptic can tolerate without inconvenience. Children bear large 
doses (2 or 3 drachms in the day) sometimes, while many adults 



248 EPILEPSY. 

cannot long endure more than 100 grains daily. The great secret of 
success in treating epilepsy by these drugs depends upon regularity 
and perseverance in the dose. Chloral added to the bromide enables 
the physician to diminish the large doses, and as Seguin has shown, the 
dose should be largely diluted with plain water or an alkaline liquid 
like Vichy. 

This treatment should be persevered in for two years after the last 
attack, and should, if possible, not be interrupted even for a single day. 
Mono-bromide of camphor in 5 grain doses has been recommended as 
a substitute for the ordinary bromides. 

The acne produced by large doses of the bromine salts is prevented 
or modified by combining arsenic with them ; rarely does the anaes- 
thesia of the palate and pharynx give any trouble, This should be 
always induced when possible, as a guide is thus obtained that the full 
effects of the drug are produced. 

The bromine treatment will be found to fail completely in a variable 
percentage of cases. In our present ignorance there is no method by 
which such cases can be recognized .until the drug is tried. Probably 
such examples of the disease will be found to belong to a separate 
group, with totally different causation and pathology. Where a suffi- 
cient trial proves the failure of the bromides, the next remedy worthy 
of a trial is belladonna or atropine. Trousseau got good results from 
this drug when used over periods of one or two years. The green 
extract of belladonna may be commenced in doses of J grain in pills, 
given three times a day, and this dose may be increased to 1 £ grains ; 
15 minims of the U. S. P. tincture may be given, or 2 to 4 minims of 
the solution of the sulphate of atropine (1 : 100) may be administered 
three times a day. Of the alcoholic extract of belladonna root not 
more than -J- grain should be given at the commencement of the treat- 
ment ; 10-minim doses of the succus, increased to 30 minims, may be 
tried. 

When belladonna also fails, the following list may be tried in the 
order in which the remedies are named : salts of copper, silver, zinc, 
gold, arsenic, phosphorus, cerium, nickel, lithium, osmium, boron, 
sodium, and nitrites. 

Of the copper salts, the ammonio-sulphate is the one recommended 
by Brown-Sequard ; \ graiu in pill three times a day will be a fair 
dose to begin with. It should not be continued beyond three or four 
months at a time. 

Silver salts have produced very good results in both forms of epilepsy, 
but serious permanent staining of the skin has so often followed their 
administration that they must be given with caution, and on no account 
should their administration be continued for a longer period than eight 
weeks, and even then some discoloration may be produced. The nitrate 
in doses of \ grain, or the oxide in doses of 1 grain, may be given three 
times a day in pills. 

Zinc salts have been much used in the treatment of epilepsy, and 



EPILEPSY. 249 

their administration is not attended with the serious drawbacks attend- 
ing the use of silver or copper compounds. The bromide of zinc may 
be given in doses of 5 grains, in water and glycerin, four times a day. 
It may be combined with other bromides. The oxide in doses of iO 
grains, the sulphate (6 grains), the acetate (4 grains), the valerianate 
(4 grains), the phosphide (-^ grain), may be given in the pilular 
form for long periods. The oxide has especial advantages in epilepsy 
occurring in children, and the valerianate in. cases associated with 
hysteria. The action of the sulphate is the least satisfactory of the 
list. 

The chloride of gold and sodium has been used as a substitute for 
the silver salts. Though there is not enough experience of its action 
to warrant a decided opinion upon its merits, nevertheless its results 
in hystero-epilepsy warrant a trial of it in epilepsy where other agents 
have failed. In doses of T V grain, in pills, it may be given for long 
periods without harm. The writer believes it to be one of the most 
valuable drugs in the treatment of epilepsy associated with organic 
nerve lesions. Bromide of gold is recommended by some authorities. 

Arsenic has been much praised in epilepsy, but it is very doubtful 
if any really permanent benefit has followed its use. The writer has 
seen marked temporary advantages follow its prolonged administra- 
tion in petit mal, where the bromides failed after long trial, in children. 
It is, moreover, an excellent tonic to give with the bromides ; and not 
only does it modify or prevent the acne which they produce, but it 
appears to lessen the risk of bromism when the bromiue treatment 
is continued for very long periods. There does not appear to be 
any advantage in increasing the dose beyond 4 minims of Fowler's 
solution. 

Phosphorus has been used and extolled, but much of the good results 
obtained from its administration may be fairly attributed to the cod- 
liver oil with which it has been often combined when ordered as a 
remedy in epilepsy. It may, however, be useful when a strict vege- 
tarian diet has been persevered with for a long time. 

Salts of cerium (3 grains of the -oxalate), of nickel (1 grain of the 
bromide in pill or syrup), or of lithium (30 grains of the bromide in 
gouty subjects), have been given with varying success. The latter salt 
acts like the other bromides. 

Osmic acid, which has been extensively used in obstinate sciatica, 
has been administered recently in epilepsy in doses of 2 minims of a 
1 per cent, solution. Wildermuth gave in intractable cases fifteen 
pills daily, each containing -^ grain of osmate of potassium, with 
benefit in several cases. 

Borax, in doses of 20 grains three or four times a day, nas 
within recent years been stated to have produced very good results 
in epilepsy, but many reliable reporters state that they have seen 
•nothing but furred tongues and gastric irritability follow its adminis- 



250 EPILEPSY. 

tration. It is stated that it has most influence over nocturnal epi- 
lepsy. 

Chloride of sodium, in doses of 1 to 2 drachms, has been followed 
by some remarkable successes in the hands of Nothnagel and others. 

Nitrites possess unquestionable power over epilepsy, but unfortu- 
nately their effects are, as a rule, temporary. Thus, nitrite of amyl, 
as already mentioned, will shorten the status epilepticus, will cut short 
the convulsions, or will prevent the seizure, in many cases completely, 
if inhaled in time, as soon as an aura is experienced. 

Similar effects may be produced by nitro-glycerin, in doses of 
2 minims of a 1 per cent, solution, and the effects are more lasting. 
The writer has described upon page 44 the method by which he 
obtains all the valuable properties of this drug in the treatment of 
angina pectoris, and he believes that similar benefits might be obtained 
in the prevention of epileptic attacks if administered in the same 
way, though he has not tried the drug in the disease under con- 
sideration. It probably will be found of great value if so prescribed 
in petit mal. 

The nitrite of sodium has been given with benefit in 'petit mal, in 
doses of 1 grain four times a day in solution. In bad cases, if each 
dose were diluted and swallowed at about six or eight times, with 
intervals of about fifteen minutes, it is probable that the fits might 
be warded off for an indefinite period. Nitrites of sodium and 
potassium have been used in the petit mal of children with some 
success. 

Where syphilis has been known to exist in a patient the subject 
of epilepsy, there should be no hesitation in beginning with small 
doses of the bichloride or biniodide of mercury. Afterward large 
doses of iodide of sodium (30 grains), three times a day, may be 
given. 

Amylene hydrate has been much praised by Wildermuth, in doses 
of 30 grains thrice daily- 

Chloral hydrate has been given to prevent or modify the seizures, 
but in the writer's opinion this is a very doubtful procedure in most 
cases. He has, however, availed himself of its anti-spasmodic powers 
in infantile convulsions, probably of an epileptic nature, and, as just 
stated, it is occasionally of great use in permitting the physician to 
diminish the amount of the bromides for a time when these disagree. 

Antipyrine and antifebrin have been tried in numerous instances, 
and have been proved to possess little beneficial influence in epilepsy, 
except when given in very large doses, and even then the results are 
often very evanescent, and are sometimes followed by more violent 
attacks when the action of the remedy passes off. 

Recently Wood has given strong reasons for believing that a com- 
bination of bromide of ammonium and antipyrine will give better 
results than are to be obtained from either remedy separately, and 
Potts has published a striking report of forty-three cases treated by 



EPILEPSY. 251 

this combination, the dose being 6 grains of antipyrine and 20 grains 
of the bromide three times a day. 

Paraldehyde has been used with some success in place of bromides 
by H. B. Williams. Its effects soon pass off, however. Of vegetable 
substances vaunted for the cure of epilepsy, there is practically no end. 
Some are, no doubt, valuable adjuncts to the treatment by the metals 
and their salts, but the great bulk of the list may be safely left aside. 
Belladonna and atropine have been already mentioned, and strychnine 
in small doses is occasionally useful. 

Camphor, lobelia, musk, asafoetida, bryonia, cocculus indicus, or its 
active principle (picrotoxine), conium, digitalis, santonin, rue, sumbul, 
ignatia, valerian, turpentine, cannabis indica, cypripedium, galium 
aparine, calabar bean, ergot or sclerotinic acid, simulo, cocaine, apo- 
morphine, caffeine, codeine, curara, have all had their advocates. 

The above is but a portion of the list of remedies, the glowing ac- 
counts of which, in epilepsy and other allied conditions, help to swell 
the current literature of therapeutics from year to year. Scarcely a 
single member of the list possesses any anti- epileptic virtues, and the 
use of many of them is fraught w r ith serious danger. 

While still dwelling upon the treatment of epilepsy during the inter- 
vals between the attacks, there are some methods not yet mentioned 
w T hich have proved to be worth trial. 

Electricity has been used in various ways. A continuous current 
may be passed through the brain from the occiput to the forehead 
(about five Leclanche elements). Three times as many cells may be 
used to the spinal column. Static electricity promises to give better 
results than the continuous current. General electrization with sparks 
from the spine may be tried. 

Considerable diminution in the severity and frequency of the attacks 
has been reported, after several weeks' application of a weak continuous 
current to the thyroid gland. 

Hypnotism has been mentioned by Liebeault, who advises the patient 
to be hypnotized between the attacks, and when in the somnambulistic 
state, suggestions should be made to him that he will not suffer from 
further attacks. The good results that sometimes follow the interfer- 
ence of so-called " faith-healers " prove the mysterious influence of the 
imagination in epilepsy, and would justify one in hoping that, when 
hypnotism is taken out of the hands of quacks and impostors, and 
scientifically applied in the treatment of disease, benefits may be ob- 
tained thereby. 

Ligature of the vertebral or carotid arteries has been recommended 
and carried into practice, but w 7 ith results that do not at present war- 
rant a repetition of such formidable operations. 

Counter-irritation, by means of blisters, and the actual cautery ap- 
plied to the back of the head and neck, has been found to produce 
benefits of no mean value in epilepsy. A seton introduced into the 



252 EPILEPSY. 

nape of the neck has been followed by cessation of the attacks for a 
long time. 

Ice to the upper part of the spine, and counter-irritants, like croton 
oil, to the scalp, have been used successfully by Brown-Sequard. 

Diet, though mentioned last, is one of the most important elements 
in the treatment of epilepsy. The writer has treated several cases of 
the disease by this means alone, and generally found very marked 
diminution in the frequency and severity of the attacks after putting 
the patient upon a purely vegetarian diet. He would, therefore, say 
that, given a case of epilepsy, the first thing to do before .administering 
drugs is to forbid animal food entirely. After a little, when under the 
influence of bromides, milk, eggs, and fish may be permitted. It is 
remarkable that many epileptics, who protest against vegetarian diet 
at the beginning, can scarcely be tempted to return to animal food after 
several months trial of this practice. 

For the prevention of attacks in those cases where a warning or well- 
marked aura is experienced, much may often be done. Tying a liga- 
ture tightly around the limb where the aura is felt, or irritating the 
region by pinching, pricking, or galvanism, may put off the seizure. 

Where contractions of muscles warn the patient that an attack is 
coming on, prompt forcible extension of the contracted limb often 
wards off the convulsions. Thus, if the head, forearm, fingers, or leg 
are bent before the attack comes on, a forcible straightening out at 
once often nips the seizure in the bud. Pressure upon the carotids at 
this stage may be equally efficacious. Nitrite of amyl, in many cases, 
if inhaled immediately after the warning, postpones the attack, or, as 
already mentioned, modifies the convulsions if already started. 

Chloroform or ether inhalations may also ward off convulsions if em- 
ployed when the aura is felt. Many other means have been discovered 
and resorted to by patients who experience warnings, thus : violent 
breathing, shouting, jumping, electric shocks, ammonia, or pungent 
snuff have been utilized by patients who have found their employ- 
ment to cause postponement of the attack. Counter-irritation to the 
spot in which the aura is felt, or blistering of the limb above the spot, 
sometimes prevents further attacks. If any portion of the body is dis- 
covered upon which pressure or irritation causes an attack to come on, 
Brown-Sequard advises counter-irritation to be applied to this region. 

Little need be said regarding the remarkable results alleged to have 
followed operative and other treatments of ocular and nasal disturb- 
ances supposed to be the cause of epilepsy. With very rare exceptions 
these have proved delusive. In cases of localized epileptic convulsions, 
where all the characters of an epileptic attack may be observed with 
a motor aura confined to one limb or one group of muscles, the lesion 
in the brain may be localized with accuracy in some cases. 

Trephining has given brilliant results in such instances where the 
symptoms of compression or irritation warranted the opening of the 
cranial cavity. 



EPIPHOKA—EPISTAXIS. 253 

Victor Horsley has published some remarkable results upon the 
operative treatment of focal epilepsy. After a few months unsuccessful 
treatment by bromides, counter-irritation, etc., and repeated observa- 
tions with the view of localizing the seat of the epileptogenous disturb- 
ance, he explores the spot by trephining ; if no gross lesion is observ- 
able upon exposure of the cortex, he stimulates it with an induced 
current, and excises the spot giving rise to the initial spasm. His 
invaluable paper, to which the reader is referred, appears in the Brit- 
ish Medical Journal, December 6, 1890. 

EPIPHORA. 

The cause must be treated when this is possible. If a stricture of th e 
nasal duct be present it must be permanently dilated. This may be 
accomplished by passing a probe down at repeated intervals through 
the narrowed duct ; to cause wide dilatation the probe may be kept in 
situ for a short time. Astringent solutions may be injected after a very 
large probe has been made to enter. 

Should there be much difficulty in passing the probe, either canal- 
iculus may be slit up for a portion of its extent. This is best done by 
inserting through either punctum a fine grooved director into the sac 
along the canaliculus, and slitting up the canal in part or in its entire 
length. After this any form of probe, medicated bougie, tent, or style, 
may be employed to keep up dilatation. 

Stilling, Weber, and others overcome the obstruction by incisions 
made with variously shaped knives, and the actual cautery and the 
galvano-cautery have been used with advantage to cause obliteration 
of the entire lachrymal sac, after milder measures have failed. 

Extirpation of the lachrymal gland has been practised. 

EPISPADIAS 

is generally associated with ectopia vesicae, and the only treatment of 
any service is a plastic operation, performed by dissecting a flap from 
the abdominal surface and two flaps from the groins, with a view to 
cover in the exposed bladder region. After the cicatrization of these 
flaps, another plastic operation, as devised by Nelaton, may be under- 
taken to remedy the epispadias. 

EPISTAXIS 

should only be stopped when the bleeding occurs under such conditions 
as warrant interference. In plethoric subjects, and in those suffering 
from congestive headaches, the discharge gives relief, and measures for 
its arrest should not be undertaken unless when the flow has already 
been plentiful. 

By placing the patient upon his back, with the shoulders and head 
moderately elevated and the arms raised as high as possible above the 
head, while pressure is made upon the bleeding nostril, most cases will 



254 EPISTAXIS. 

speedily stop. Should this fail, cold compresses of ice to the temples 
and occiput, and sinapisms to the calves of the legs, may be tried. The 
reflex action following these applications often speedily causes closure 
of the bleeding vessels, through the vasomotor supply. Hot foot baths 
and hot water bags to the spine may be useful. 

When these measures fail, astringent lotions may be applied upon 
plugs of cotton wool or lint, which should be gently pushed up the 
bleeding nostril with forceps. In this way tincture of iron or the strong 
liquor (1 : 2), spirit of turpentine, concentrated solutions of alum or 
tannin, styptic colloid, etc., may be used. The writer's method is 
however, much better, and he has seldom failed by it in arresting 
copious hemorrhage, even when this has been the direct result of 
injury, as in removing polypi, etc. It consists in drying out the cavity 
of the nostril with plugs of absorbent wool, and rapidly inserting small 
masses of the puff-ball (licoperdon giganteum) until the nostril is com- 
fortably distended with the fungus. (See fifth edition of the author's 
Materia Medica and Therapeutics, page 581.) The plugs of this sub- 
stance may be left in situ. They come away in a few days if left to 
themselves. 

India-rubber collapsible bags are made, and can be obtained from 
any instrument maker ; after being inserted they are blown up with 
air, and can be made to exert a uniform, firm pressure upon every 
recess in the nasal chamber. They are cleanly and effective. The 
writer has, however, discarded them for the puff-ball, because the in- 
flated bag, with its dependent tubing and stop- cock, is, as a rule, so 
unsightly, as to prevent the patient, for the time, pursuing his ordinary 
avocation. Should the hemorrhage be far back, one of these bags may 
be inserted through the mouth, and, after inflation, it can be pulled 
forward by means of its attached tube brought out through the ante- 
rior nares. 

By means of the nasal douche, a stream of astringent solution may 
be made to pass through the nasal cavity and out of the opposite nos- 
tril, if the palate be elevated by keeping the mouth wide open. Fresh 
lemon-juice is highly recommended as an injection. Hot water may 
be so employed with great advantage, as in post-partum hemorrhage. 
Astringent powders may be blown in by the insufflator. Ergot and 
other haemostatics, by the mouth or hypodermically, are generally useless. 
The writer has never seen them do any good, but they may be tried. 

Should all these measures fail, there will be no resource left to the 
surgeon but to plug the nostrils (with a roll of lint) from the posterior 
nares. This is one of the simplest and least painful of operations in 
the eyes of the surgeon — until he has tried it. Having once performed 
it, he will hesitate to repeat or recommend it. It should never be under- 
taken unless the loss of blood is serious. By means of a Bellocq's 
canuia, a thin double whipcord or hempen ligature is passed through 
the nostril, and one end brought out through the mouth. To this end 
compact roll of lint, large enough to block the posterior nares is 



EPULIS — ERYSIPELAS. 255 

attached. Traction upon the cord in the nostril hauls the lint tightly 
against or into the aperture of the posterior nares, where it is held in 
position by a plug of lint packed into the nostril in front. Over this 
plug the ends of the cord may be tied so as to render displacement 
impossible. It is advisable to leave a piece of string attached to the 
plug behind ; this may be left hanging in the pharynx, or it may be 
left projecting from the mouth. By pulling upon it, the posterior 
plug can be removed at any time through the mouth without difficulty. 

Greville MacDonald finds that the erosion or venous rupture which 
causes epistaxis, is almost invariably situated upon the anterior portion 
of the septum, and can be reached by a speculum and good light, 
when the galvano or other cautery may be brought to bear upon it 
with definite results, or a small anterior plug may be inserted. Every 
surgeon will agree with him, when he states that posterior plugging is 
never necessary except in rare cases of post-nasal hemorrhage. 

Where death threatens from loss of blood, transfusion should be 
performed. (See under An?emia, page 36.) 

EPULIS. 

Unless the portion of the alveolar process from which the growth 
springs be entirely removed, the tumor is almost certain to return. A 
tooth upon each side of the epalis having been extracted, the limits of 
the incision in the gum may be marked out by two vertical cuts made 
by a fine saw. Between these points the grpwth and adjacent alveolus 
is cut out by sharp pliers. The actual or galvano-cautery may be 
used when the epulis is small. 

ERYSIPELAS. 

The treatment of this affection wall embrace (1) constitutional and 
(2) local measures. 

Everything tending to depress the vitality of the patieut must be 
avoided. Bleeding, leeching, and profuse purging — favorite methods 
of treating erysipelas in times past — are always contra-indicated. A 
diet of the most sustaining and easily digested food should be given, 
solid meats being forbidden till fever disappears. A liberal allow- 
ance of good soup, beef tea, or chicken jelly, with milk in large quan- 
tity is essential. 

In severe cases, alcoholic stimulants are always indicated. It is a 
mistake to give stimulants alone ; when possible, they should be incor- 
porated with the food. Thus, whiskey or good brandy may be mixed 
with the milk (one wineglassful to each pint or quart) ; and port wine 
(one wineglassful to each pint of beef-tea) may be given almost ad 
libitum. The writer has seen harmful results follow the injudicious 
order to give unlimited alcohol in severe cases. Sometimes the patient 
takes the stimulant to the exclusion of food ; this is sure to lead to 
serious trouble. This is got over by laying down the rule that the 



256 ERYSIPELAS. 

stimulant is to be mixed with the food. The previous habits of the 
patient, the stage at which the disease is found when the case comes 
under the physician's notice, the condition of the heart and vessels 
and the amount of cutaneous surface involved, and the temperature, 
will give valuable aid in arriving at a conclusion about the amount of 
alcoholic stimulants necessary. As a rule, very large amounts are 
well borne, especially in erysipelas following operations in intemperate 
or irregularly-living subjects. Mild cases will require no stimulants ; 
they do better without them. 

Before commencing medicinal treatment, one smart, saline purge 
should be administered in order to thoroughly empty the intestinal 
canal. A mercurial may be given eight hours before the saline if the 
patient be robust, but it should not be repeated. 1 ounce Rochelle 
or 4 drachms of Epsom salt may be given in a tumblerful of lemonade. 

Of the various drugs recommended from time to time for internal 
administration there are but a few deserving of confidence. These 
are in the order of merit : iron, quinine or bark, aconite and sulpho- 
carbolates or salicylates, and jaboranoli. 

Iron, to be of any use, must be given in large doses — 30 to 60 minims 
of the tincture every two, three or four hours, according to the extent 
of local mischief or in proportion to the severity of the constitutional 
symptoms. The writer has seen it often do good and cut short the 
affection, but he has sometimes found it to fail completely. If there 
be high temperature, with^great prostration, from the beginning, the 
iron treatment must be reinforced w 7 ith quinine or tincture of cinchona. 
The best results will not be obtained by combining these drugs before 
administration. Though it is difficult to explain, the writer believes 
that by giving 40 minims of the tincture of iron every six hours, 
alternating with doses of 4 or 5 grains of quinine every six hours — i. e., 
a dose of either drug every three hours — the effect will be better than ii 
given together. 

Should there be evidence of cardiac failure early in the disease, it 
is unwise to press iron ; then teaspoonful doses of the tincture of yellow 
bark, mixed with an equal amount of aromatic spirit of ammonia, 
and a half ounce of brandy every two hours may be given, well diluted 
with water. 

Aconite is extolled. It may be given advantageously where at the 
very beginning there is high temperature, a dry skin and tongue, with 
a bounding pulse in strong subjects. The dose should be small and 
should be repeated every hour, and the remedy should not be con- 
tinued after the end of the second day unless there be a fresh invasion 
of other regions. Tison recommends that the crystallized aconitia be 
administered. The symptoms rapidly yield to this method of using 
the drug, and mild cases quickly get well. Such patients generally 
recover rapidly in any case, and it is doubtful if real permanent 
benefit follows the routine administration of aconite in erysipelas. 



ERYSIPELAS. 257 

Tartar emetic acts in the same way, if given very frequently in 
minute doses. 

Sulphocarbolate of sodium, in doses of 25 or 30 grains, given every 
six or eight hours, sometimes succeeds where all these remedies fail, 
especially where there is diffuse cellular inflammation. 

Boric acid might act better in 10 to 15 grain doses, or benzoate of 
soda in doses of 30 to 40 grains every six hours. 

Belladonna has been recommended ; it may he given with ammonia 
or digitalis should the circulation be much depressed. Pilocarpine 
hypodermically (4- grain) has been recommended in idiopathic ery- 
sipelas and many very favorable reports of its value have been 
received during the last few years. 

As regards the real use of internal remedies in erysipelas, the way 
is being cleared up greatly by recent pathological discoveries. It is 
clearly demonstrated that the disease is caused by the presence of a 
parasite, and hence the prevailing opinion that internal treatment can 
only be of use in correcting the poisonous effects of certain ptomaines 
or albumoses secreted by the streptococcus. This view does not 
entire y meet the. case ; it is clear that phagocytosis plays a very im- 
portant part in recovery, and remedies like iron and quinine probably 
assist the phagocytes in their work of destruction. The pathology or 
the disease proves the importance and necessity of local antiseptic 
treatment. 

The local treatment of covering the inflamed surface with some 
harmless or inert substance, to exclude the air and protect the part 
from variations of temperature, has been practised from the earliest 
periods. 

Of the innumerable methods from time to time suggested, the most 
popular is that of sprinkling dry flour or powdered starch over the 
affected part till a thick layer lies evenly upon its surface. This may 
be achieved by using a common flour dredger. 

White lead paint has been successfully employed ; it is less likely 
to be brushed off by friction, and it keeps out the air and is thus sup- 
posed to rob the erysipelas cocci of the oxygen necessary for their 
growth and multiplication. Hewson uses an earth-dressing consisting 
of clay and water. Various other paints are used with the same 
intention — collodion, traumaticine, or the U. S. P. solution of gutta- 
percha, carbolic oil (1 : 8). Belladonna and glycerin ointments are 
also useful by excluding air and preventing the growth of the parasite. 
The best results are obtained by smearing the part freely over with a 
mixture of lanoline and ichthvol in equal parts, and then enveloping 
it in salicylated cotton-wool as practised by Kussbaum. He states that 
it is seldom necessary to continue this treatment beyond three days, as 
pain, redness, and itching disappear rapidly after the first application. 
An ointment of sulphate of iron (1 drachm) andlard (2 ounces) is also 
a very good preparation. Duckworth uses an ointment composed of 
equal weights of prepared or precipitated chalk and lard, to which 6 



258 ERYSIPELAS. 

per cent, carbolic acid is added, and covers the part with boric lint. 
There are several means by which a local attempt may be made to 
prevent the disease from spreading. Higginbotham's " ectrotic " 
method consists in painting a strong solution of nitrate of silver (1 
drachm to 1 ounce) upon the healthy skin around the margin of the 
diseased spot. The solid stick may be used after moistening the skin 
with distilled water. The writer has often observed striking results 
follow the application of liniment of iodine when used in this way. 

Many surgeons now treat the disease by limiting its margins by the 
application of strips of adhesive plaster, which by their pressure pre- 
vent the spread of the parasite along the underlying compressed 
lymphatics, while others use the pressure of rubber or elastic bands 
for the same purpose. Both these plans are uncertain in their results. 

Bromine solution may be used to surround the diseased area, and 
some surgeons apply it also over the affected surface. Collodion may 
be painted in a ring around the diseased spot. Carbolic acid (2 per 
cent, to 30 per cent.) may be injected with a hypodermic needle into 
the subcutaneous tissue around the affected region. Salicylic acid 
(concentrated solution) is used in the same way by Petersen, and Wilde 
nses sulphocarbolate of sodium solution (8 per cent.). Resorcin (5 
per cent.) has been also injected. 

These injections are doubtless highly efficacious, but they are pain- 
ful, and not entirely free from danger, and the great majority of cases 
will certainly yield to ointments. The recent plan of making several 
small incisions around the diseased spot with a knife or vaccination 
comb, and then applying antiseptic solutions, is most certainly curative, 
but most painful. 

Professor Koch's great remedy is creolin. He uses the following 
combination, and covers it over with oiled silk, and believes that 
decomposition occurs, iodine being set free : 

R. — Creolini gj. 

Iodoformi giv. 

Lanolini gx. — M. 

S. — To be smeared over the skin or applied upon lint to the diseased spot 
and beyond its margins, and then to be covered with oiled silk. 

Creasote, made into a paste with kaoline, is smeared over the dis- 
eased surface by Marshall. Valette applies a 30 per cent, solution of 
chloride of iron. Dewer uses a mixture of equal parts of glycerin 
and sulphurous acid. Shoemaker recommends the ointment of oleate 
of bismuth. Rosenbach gets best results from the constant painting 
of the diseased surface with a 5 per cent, solution of carbolic acid in 
rectified spirit. Turpetine, picric acid (10 grains to 1 ounce), sul- 
phate of iron (1 : 100), tincture of iodine, nitrate of silver (1 : 10), 
boric acid (concentrated solution), bichloride of mercury (1 : 1000) 
infusion of digitalis, permanganate of potassium (1 grain to 1 ounce), 



erythemaa 259 

have been used. As a rule, lotions are unsuitable in erysipelas where 
the skin is unbroken. Dry heat is essential, variations of heat and 
cold are certainly to be avoided, and poultices are, generally speaking, 
very harmful, unless to relieve the tension caused by the suppurative 
process. 

In the great majority of mild cases, the best treatment will be to 
cover over the surface with flour, mixed with half its weight of boric 
acid, apply a thick pad of absorbent wool, and elevate the part 
affected. Seldom will there be any necessity for using a single mem- 
ber of the above formidable host of remedies. In erysipelas of the 
head and face, there is much incovenience caused by the usual mask 
of lint, with flour and boric acid underneath ; the ointment, composed 
of equal parts of ichthyol and lanoline, leaves nothing whatever to 
be desired in such cases. It may be freely smeared on the face and 
scalp several times a day. Ichthyolized collodion is a splendid appli- 
cation in such cases. 

Pain and smarting may be relieved by smearing over the part with 
a paint composed of 1 ounce of extract of belladonna, rubbed up with 
4 ounces of glycerin, when these symptoms have not yielded to the 
ichthyol ointment. 

The cellulo-cutaneous and diffuse cellular erysipelas are to be treated 
in the same way. Stimulants and nutritious concentrated liquid nour- 
ishment and free ventilation must be insisted upon. The local treat- 
ment, as described, should be carried out, and, as soon as tension is 
observed, hot charcoal poultices and free incisions may be resorted to, 
after which the suppurating wound may be treated with weak lotion 
of corrosive sublimate. 

ERYTHEMA. 

Under this heading are included by most writers a variety of affec- 
tions. Their differentiation is not, however, a matter of much im- 
portance, as they mostly tend to get well if left alone, and their treat- 
ment, therefore, is comparatively simple. 

The cause of the erythema should be found out, and remedied, when 
possible. This is essential in chronic or ofc-recurring attacks. 

Dyspepsia and gastric catarrhal conditions are answerable for many 
of these cases, and the state of the stomach and its digestive powers 
must be carefully remedied by appropriate treatment. (See under 
Dyspepsia.) 

The erythema so common after eating shell-fish, pork, salt meats, 
etc., and commonly called urticaria, is generally found to cease after 
the offending article of food is discovered and discontinued. The 
urticaria or erythema following the administration of iodide of potas- 
sium, cubebs, copaiba, or turpentine soon ceases when these drugs are 
stopped. Should the affection appear without obvious cause, alkalies, 
combined with bitter tonics, may be tried first. Thirty grain doses of 



260 ERYTHEMA 

bicarbonate of soda or potash, with 10 grains of carbonate of bismuth, 
in half an ounce of infusion of chiretta, is an excellent combination. 
The writer's favorite ihixture in such cases is the following : 

Be . — Liq. magnesii carbon. B. P. (fluid magnesia) . % x. 

Tinct. rhei ........ J;jss. 

Glycerini purif. . . . . . . ^ ss. — M. 

S. — Take a large spoonful three times a day, two hours after meals. 

If this be insufficient to cause mild purgation, one dose (2 to 4 
drachms) of sulphate of magnesia should also be given each. morning, 
in a tumblerful of potash water. 

Small doses of tartarized antimony seem to exert some specific 
action upon erythema or chronic urticaria, and cases are occasionally 
met with where this agent relieves, after all other plans, both internal 
and local, have failed. Two grains may be added to the above mix- 
ture. 

While the stomach, liver, renal, or other affections are being treated 
by appropriate remedies, the local treatment of the case should be 
attended to. 

Itching may be relieved by lotions of alkalies or of lead when the 
affection is local, and by tepid baths of bicarbonate or carbonate of 
soda (J pound to 20 gallons) if the general surface is involved. Where 
warm or tepid baths aggravate, great comfort may be obtained by 
sponging over the body piecemeal with solution of bicarbonate of soda 
(1 ounce to 40 ounces of water). Cloths moistened with such solution 
may be allowed to remain in contact with the itching part. A good 
lotion, when the soda solution fails, is one composed of 1 ounce of 
strong solution of subacetate of lead in 3 pints of distilled or rain 
water. To this half a pint of spirit of wine may be added. Borax 
(1 ounce to 3 pints of water) may be useful when this fails. 

Hydrocyanic acid (1 drachm, to water 15 ounces) may be used 
upon lint, and covered with oiled silk. 

Evaporating lotions often give relief, when bathing, sponging, and 
other means fail. 

The following may be applied with a brush or sponge, and allowed 
to dry : 

R. — Eau de Cologne ^ij. 

Zinci oxidi ^ ss. 

Liq. carbon, deterg. . . . . . . . 5§ss. 

Aquae dest ^ x vij. — M. 

S. — To be used as directed. 

Scratching should be forbidden, and variations of temperature, espe- 
cially exposure to dry heat, always aggravates. 

Sometimes the method of applying dry powders, as in the treatment 



EXOSTOSIS. 261 

of erysipelas by flour, oxide of zinc, starch powder, or calamine, gives 
relief. 

Erythema multiforme, annulare, or papulatum may be treated in a 
similar way. Often the writer has seen the ordinary treatment for 
acute rheumatism (salicylates or alkalies) do much good. When 
bullae form, ointments, such as the official zinc ointment, should take 
the place of lotions. 

Erythema nodosum is often accompanied by severe pain, and calls 
for special treatment. The elevation of the limbs may give much 
comfort. Lotions of lead and opium may be applied on lint, and 
covered with oiled silk. The swellings may be painted over with col- 
lodion. The writer has obtained the best results by enveloping the 
legs in several layers of warm, absorbent wool, and applying, with 
moderate pressure, a light calico or woven bandage from the toes to 
the knee, while the patient is kept in the horizontal position, with the 
limbs somewhat elevated. Should there be any erythema multiforme 
also present, salicylic acid or its soda salt may be given. In very 
painful cases, a warm poultice, smeared over with the green extract of 
belladonna, or fomentations of poppy capsules, may be tried, but, as a 
rule, moist heat is not suitable. 

Erythema intertrigo is best dealt with by removing all irritating 
secretions by gently rubbing the opposing or overlapping layers of 
skin with an oiled pad of wool or fine muslin, and dusting freely over 
with zinc powder, Fuller's earth, starch, or other harmless powder. 
The erythematous surfaces in fat people should be kept separated by 
a double fold of lint sprinkled with any of these powders, or the lint 
may be smeared over with zinc or lead ointment. In infants the in- 
tertrigo about the genitals and nates should be covered over with a 
firm ointment composed of zinc ointment 2 ounces, powdered cala- 
mine 2 drachms, and powdered starch 4 drachms. 

For the treatment of Erythema Pernio see Chilblains, page 119. 

EXOPHTHALMIC GOITRE— See Goitre. 

EXOSTOSIS. 

When the peduncle is small the growth may be removed with chisel 
and mallet, gouge, sharp spoon, saw, cutting pliers, or bone forceps. 
Sometimes after exposure the knife will be found sufficient when the 
base is fibrous and not bony. The majority of exostoses should be 
left alone, unless by their presence they are causing disturbance or 
producing deformity. Hard or ivory growths upon the cranial bones 
may be removed by freely exposing their bases, and applying from 
time to time strong sulphuric acid to the peduncle until the death of 
the exostosis is produced. This result sometimes follows ineffectual 
attempts at removal of the growth. The galvano-cautery may be 
tried, but it is of little use save in cases which could easily be other- 
wise treated. 



262 EXTRA-UTEEINE FCETATION. 

EXTRA-UTERINE PCETATION. 

In the early months of tubal pregnancy, when this condition is sus- 
pected, absolute rest in the horizontal position must be insisted upon, 
and no straining or violent expulsive effort permitted. Colic and 
pain should be relieved by morphine, antipyrine, or any narcotic. 
The object at this stage (up until the third or beginning of the fourth 
month) should be to prevent rupture of the cyst, and up until the ex- 
piration of this period there is ground for hoping for the natural death 
of the foetus and absorption or atrophy of its tissues. 

Duncan strongly condemns all electrical, tapping or injecting 
methods of treatment in early tubal gestation as uncertain and dan- 
gerous. He urges that as the woman's life hangs upon a thread which 
may snap at any moment, the abdomen should be opened without 
delay. 

Innumerable plans have been devised to cause the death of the foetus. 
These have, for the most part, ended in failure, or they have produced 
rupture of the cyst and the death of the mother, though still, many 
insist upon the value of the interrupted current By far the best re- 
sults have been obtained by making an exploratory abdominal inci- 
sion, through which the foetus may be removed if the diagnosis prove 
correct. This line of treatment is also applicable to those cases where 
rupture has already occurred. 

Where there is evidence that rupture of the tube has already taken 
place there is no doubt about the wisdom of an immediate operation 
as soon as the patient can be rallied by ether and stimulants from the 
profound collapse sometimes resulting. 

But when rupture takes place into the cavity of the broad ligament 
the case really becomes one of broad ligament hematocele, which if 
tapped or interfered with almost always ends fatally. If let alone the 
case is nearly certain to make a recovery though a slow one and sup- 
puration may eventually result. 

Dr. Strahan in his admirable prize essay on Extra-uterine Preg- 
nancy, forcibly points out the surgeon's duty in cases where rupture 
has already occurred, not a moment is to be lost in opening the 
abdomen, and if the extreme prostration of the patient forbids opera- 
tion she should be rallied by hypodermic injections of ether and intra- 
venous injection of weak saline solution. He gives some striking 
instances of " resurrection " after the use of these means, and the 
hypodermic injection of 10 minims of a 1 per cent, solution of nitro- 
glycerin followed by atropine. 

After making an incision as for the removal of an ordinary ovarian 
turner, the cyst containing the foetus is exposed, and attached by sutures 
to the abdominal wound, after which it is opened freely and the foetus 
removed. It is necessary to leave the placenta which, however, should 
be well drained through the cord to get rid of all available blood ; it 



favus. 263 

can be removed afterward. The cavity of the cyst must be well washed 
out with antiseptics and proper drainage established. 

Tait's method of dealing with the placenta is a very great advance 
in the surgery of this serious condition. He cuts off the umbilical 
cord as close as possible to the placenta, and after emptying the cyst 
of its fluid contents he hermetically shuts in the placenta in the cyst 
by accurate closing of the incision in the cyst-walls. He has also 
demonstrated that in those advanced cases where there is much disten- 
sion of the broad ligament, the abdominal incision, if made well beyond 
the middle line on the side occupied by the tumor, will enable the sur- 
geon to perform an extra-peritoneal operation, owing to the parietal 
peritoneum having been stripped off the pelvic and lateral abdominal 
walls. 

Where cases of tubal pregnancy do not present themselves until the 
fifth or sixth month, the serious question arises about attempting to 
wait in order to give the foetus a chance for life. In the absence of 
any symptoms of urgency this may well be done, but the greatest watch- 
fulness and care must be daily exercised, the surgeon being prepared to 
operate by the lateral incision upon a moment's notice. 

The operation may be performed through the vaginal walls by cut- 
ting through into the cyst with the cautery, but by far the best results 
follow the free abdominal incision. 

The following are some of the methods proposed, and sometimes suc- 
cessfully carried out with the view of destroying the foetus : 

1. Tapping the cyst and removing the liquor amnii. 

2. Electricity : a. By sending a strong continuous or interrupted 
current through the cyst ; b. By passing a current of static or fric- 
tional electricity by a Leyden jar from the rectum and through the 
vagina ; c. By galvano-puncture. This last is a most dangerous pro- 
ceeding. 

3. By the injection of narcotics as morphine, and antiseptics into the 
cyst. Gossman still insists upon the certainty and safety of hypo- 
dermic injections of 1 grain morphine into the sac. 

4. By destroying the life of the foetus through the mother by inducing 
mercurialization, mild strychnine, or other poisoning, or by giving 
ergot and purgatives. This barbarous treatment has been seldom tried. 
It has even been proposed to induce syphilis in the mother. 

FAVUS 

The management of this troublesome parasitic disease taxes to the 
utmost the patience of the physician. At the beginning, the reader 
may be reminded that the parasite will not live upon a healthy being. 
Hence the first indication for treatment will be to find out the " depar- 
ture from health," and bring appropriate remedies to bear upon it. 
Pure air, good food, outdoor exercise, and warm clothing, with regu- 
larity in living, are essential. Failing nutrition must be met with cod- 



264 FEBRICULA. 

liver oil and malt extracts, and the appetite should be stimulated by 
small doses of quinine with the mineral acids. 

Local treatment must be vigorously and perseveringly pushed. The 
first step to be taken is to get rid of the accumulated crusts. This is 
best done by enveloping the scalp in a cap of lint soaked in spirit lotion 
and covered over with oiled silk. Poulticing and oiling are not satis- 
factory, but they may be resorted to occasionally for short periods. 
Epilation and parasiticides are the main remedies to be relied upon in 
the tedious struggle against the achorion Schonleinii. Blistering is to 
be pressed into the service occasionally, with the view of making way 
for other remedies to reach the parasite. All the remedies useful for 
ringworm of the scalp may be used against favus, and success depends 
more upon the judicious way in which these agents are used one after 
the other than in the persistent use of any of them. Thus, a solution 
of sulphurous acid (1 : 4) may be applied for some time until all the 
fungus confined to the surface is destroyed. A spray of sulphurous 
acid gas has given good results. Then a solution of corrosive sublimate 
(1 : 250 of spirit and glycerin) may be applied for a few weeks. 
Afterward, creasote, resorcin, carbolic acid, salicylic acid, thymol, myr- 
tol, or oleum menthse pip. may be applied in solution in spirit to which 
a little chloroform has been added. 

If a greasy preparation or ointment be selected, the scalp should be 
well oiled to remove crusts, after which a weak ointment of iodide of 
sulphur (20 grains to 1 ounce) may be well rubbed in. It is the most 
reliable preparations of its class. The oleate of mercury ointment (5 
per cent.) may be used with advantage. Epilation must be resorted 
to, and the process carried out with care and patience. A weak, con- 
tinuous current by means of sponges soaked in sublimate solution has 
been recommended. It is clearly demonstrated that the disease is con- 
veyed from the mouse to the cat and then to the children who nurse or 
play with the affected cat. 



FEBRICULA. 

The physician will constantly meet with cases where the only depar- 
ture from health that can be noticed will be found in the increased 
temperature. Such cases may be safely let alone until the cause of the 
fever declares itself. Simple febricnla lasts but a short time (forty- 
eight hours), and though a satisfactory termination may be safely cal- 
culated upon without treatment, nevertheless it is in the power of the 
physician to give very marked relief to symptoms. The same may be 
said in those cases where the feverishness is depending upon some other 
cause. 

The patient should get a saline purgative ; 6 drachms of Rochelle salt 
in a tumblerful of lemonade is an efficient, speedy, and agreeable 
cathartic in such cases. He should be put to bed, he should have light 



FEVER — FRACTURES. 265 

bed-clothing, and should only be permitted to take liquid food, as milk, 
rennet, whey, com flour, arrowroot, gruel, weak tea, toast water, barley 
water, etc. The hot, dry skin should be induced to act by diuretics 
and diluent drinks. The following are good combinations for this 
purpose : 

R. — Tinct. aconiti Tttviij. 

Aqua? camph. . ^vj. — M. 

S. — Take a dessertspoonful every hour. 

Or, 

i&. — Liq. ammon. acet. ^ij. 

Spt. setheris nitrosi gij. 

Potassii citratis . 3 v. 

Aqua? camph. ad ^ viij — M. 

S. — Take a tablespoonful every hour. 

Lemon-juice made fresh and diluted with hot water or warm barley 
water may be given ad libitum, or the lemon-juice may be administered 
with effervescing potash water or ice. 

Antipyretics proper, as antifebrin, antipyrine, cold baths, etc., are 
not indicated in the treatment of febricula, or for the relief of a simple 
feverish condition depending upon some passing cause. 

FEVER. 

Under the heading of the different fevers, as typhus, typhoid, rheuma- 
tism, measles, scarlatina, etc., the treatment of the fever state, and of 
hyperpyrexia, will be mentioned. 

FISSURE— See under Anus, Fissure of (p. 46). 
FISTULA— See under Anus, Fistula of (p. 47). 
FLATULENCE— See under Dyspepsia (p. 218). 
FRACTURES. 

The treatment of fractures is to be carried out on the simple prin- 
ciple of reducing any deformity by bringing the broken fragments of 
the bone together and securing them in this position by suitable splints, 
so padded as to overcome any tendency to override or return to their 
abnormal position. 

As soon as a fracture comes under the care of the surgeon, no time 
should be lost in carrying out these principles. As in the case of dis- 
locations, the great barrier to reduction is the reflex contraction of the 
muscles, and the sooner the attempt at restoration of the broken frag- 
ments to their normal position, the easier will the operation become. 
The popular idea of the importance of " setting " a fracture as soon as 
possible after its occurrence is therefore based upon sound pathology. 

18 



266 FRACTURES. 

After the removal of the patient's clothing he should be placed upon 
a firm hair mattress, and the most gentle and thorough examination of 
the injured limb should be carried out, after which the surgeon, when 
all his appliances are at hand, proceeds to reduce the deformity. This 
should in all cases be achieved without the use of force, by so arranging 
the position of the limb as to cause the most complete relaxation of the 
muscles. 

Rough handling may convert a simple into a compound fracture at 
this stage of the proceedings ; hence the great necessity for obtaining 
the fullest relaxation of the muscles, so that the fragments may be 
brought accurately together without any pulling or hauling of the 
limb. This is achieved by an assistant grasping the limb firmly above 
the seat of fracture, while the surgeon makes very gentle traction 
upon the lower part, during which the bones come into apposition, 
guided by the gentlest pressure of the fingers when necessary. 

Having secured accurate adjustment of the bones, a well-padded 
splint of wood, gutta-percha, perforated tin or zinc is applied on each 
aspect of the limb. These splints should be so shaped, moulded, or 
lined with padding as to apply when bandaged an even pressure over 
the limb. As they are adjusted to the fractured member the gentle 
extension or traction is to be kept up until the whole is enveloped in a 
good calico bandage. The use of a few straps and buckles to secure 
the splints in position before the application of the bandage is a great 
convenience. Much skill and experience is required in graduating the 
pressure of the bandage, which should not be tight, and the seat of 
fracture should be left free and exposed when possible. 

After the bandaging, the limb must be carefully maintained in the 
position which affords the most complete relaxation of the muscles. 
The less it is interfered with the better, though careful inspection is to 
be constantly maintained, lest the bandages may get tight from subse- 
quent swelling, as gangrene might thereby result. 

The surgeon satisfies himself from time to time by passing his finger 
over the seat of fracture that the fragments are kept in position, and by 
passing his eye over the entire limb, and contrasting it with its fellow 
on the sound side, he sees that no rotation or deformity arises. 

Cotton-wool affords the most tempting padding ; it should, however, 
be very sparingly used. The writer, when in charge of the fracture 
cases in his house-surgeon days, discarded it entirely, owing to its 
liability to become lumpy and uneven, and used instead, a padding of 
strips of good old flannel, which answer every purpose perfectly. 

In addition to the splints applied to the broken bone, it will be 
often necessary to use others, with a view of securing complete rest 
to the joints above and below the fracture, when their movement tends 
to disturb the position of the fragments. Extension and counter-ex- 
tension may be required in special cases. Space will not permit of 
any enumeration of the various special appliances which are used in 
the treatment of different fractures. Those of them of any use fulfil 



FROST-BITE. 267 

their purpose only in as far as they carry out the simple indication of 
insuring rest and accurate approximation of the ends of the broken 
bone, while nature makes good their repair. 

Plaster, starch, glue, poroplastic felt, and other immovable casings 
may be used when the surgeon considers it necessary to permit the 
patient to move about. They are, if applied from the first, open to 
the serious objection of hindering inspection at the seat of fracture, 
but if applied after the progress of repair has been well and satisfac- 
torily started, they are among the most valuable adjuncts which the 
surgeon can command in the treatment of simple fractures. 

The time during which immobility is to be kept up varies much in 
different cases. Less than four weeks suffices in young subjects, but in 
the old more than twice this period may be necessary. As a rule it 
may be said that the mistake is sure to be made of keeping the entire 
limb in a state of absolute rest long after the necessity for such has 
passed away, to the great retardation of recovery. In most cases 
gentle massage or kneading, and cautious passive movements, may be 
commenced after the middle or end of the third week, the splints being 
again applied. This effectually prevents the formation of adhesions, 
and greatly increases the vitality of the tissues and minimises subse- 
quent pain and stiffness. 

Compound fractures are to be treated upon the same principles, with 
the addition of remedies suitable to the condition of the wound. All 
portions of loose bone are to be removed, the wound most thoroughly 
cleansed by washing out with antiseptic solutions, and if accurate 
approximation of the main fragments be not possible, excision of pro- 
jecting spiculae may be required. Thorough drainage must be secured 
where there is no hope of rendering the wound aseptic, and the limb 
so bandaged as to permit of daily inspection and dressing. Amputa- 
tion or excision of the joint may be called for. 

FRECKLES— See Chloasma (page 121). 
FROST-BITE. 

The affected part, if gangrene or vesication has not already set in, 
may in most instances be brought to its normal condition, even if 
white, hard, and insensible, by the judicious application of heat. The 
heat of the patient's own blood is by far the most effectual way of 
restoring the vitality to the benumbed part, and the way to secure this 
is by stimulating the local circulation through friction. 

The sudden application of artificial heat may be followed by too 
rapid reaction, congestion, inflammation or gangrene. The gradual 
restoration which follows vigorous friction with dry snow is the most 
satisfactory termination. The part should be afterwards enveloped in 
fur, dry wood, or flannel. 

Where gangrene has already occurred, the surgeon will probably 
find amputation necessary. As a rule, it will be advisable to use 



268 GALL-STONE. 

antiseptics freely and to wait for a well-marked line of demarcation 
if there be but a small bulk of tissue destroyed. Where the gangrene 
affects a very superficial film of tissue, bichloride of mercury (1 : 2000) 
or permanganate of potassium (1 : 400) may be freely used. 

FURUNCULUS- See Boils (page 70). 
GALL-STONE. 

The treatment will in the first instance, be directed to the relief of the 
agonizing pain produced by the passage of the stone along the ducts. 
Afterward measures may be tried with the view of causing the solu- 
tion of the calculus, or of preventing the formation of new ones. 

The pain is best relieved by a hypodermic dose of morphine Q- grain 
or more). Morphine (J grain), opium (2 grains), chloral (20 grains), 
belladonna (f grain of the green extract), antipyrine (20 grains), 
antifebrin (8 grains), ether (30 minims), turpentine (20 minims), may 
be given in suitable vehicles by the mouth if nausea or vomiting be 
absent. The dose may be repeated at intervals proportional to the 
severity of the pain. The hot bath (water at a temperature of 104° — 
108° F.) sometimes affords considerable relief. The patient should be 
kept immersed in the bath, under the surveillance of the physician or 
of an experienced attendant, until signs of weakness are observed. 
This treatment may often ward off attacks of pain if resorted to very 
early. Hot fomentations, local hot packs, and poultices, may be tried 
where a hot-bath is not at hand. Copious draughts of hot water, alone, 
or containing bicarbonate of soda (20 grains), may be given, and may 
be repeated notwithstanding the presence of vomiting. 

Emetics often afford marked relief, and the writer has found patients 
resort to their use without being instructed, having themselves dis- 
covered the relief which had followed spontaneous vomiting in former 
attacks. Sulphate of zinc (30 grains), ipecacuanha (20 grains), tartar 
emetic (1 grain), apomorphine (y 1 ^- grain hypodermically, i grain by the 
mouth), mustard (a teaspoonful in 10 or 15 ounces of water), may be 
administered. Counter-irritation may give relief in some cases. 
Should the pain baffle the above list of remedies, chloroform or ether 
inhalation may be resorted to. 

In patients, subject to attacks of biliary colic, the following mitrail- 
leuse may be left in their hands for use in emergencies until the arrival 
of the physician : 

]&. — Olei mentkse pip gij. 

Spt. chloroformi . . gvj. 

Spt. setheris sulph. 3vij. 

Morphinse hydrochlor. . . . . . . gr. ij. 

Tinct. cannab. ind giij. 

Spt. amnion, aromat ad ^iij. — M. 

S. — A teaspoonful to be taken with a tablespoonful of whiskey in a wine- 
glassful of water when the pain comes on. To be repeated in half an hour if the 
pain continues, and every four hours afterward until relieved. 



GALL-STONE. 269 

Should vomiting continue after the attack, it may be relieved with 
lemon-juice and alkaline effervescing mixture, ice, bismuth and hydro- 
cyanic acid, or sinapisms over the abdomen. Morphine perules, con- 
taining jJg- grain each, generally afford marked relief and check 
retching. 

During the intervals between the attacks, the patient should be 
advised to take free open-air exercise several times daily, and, if pos- 
sible, to give up sedentary habits or occupation. Diet should be plain, 
and only in amount sufficient to thoroughly maintain nutrition, all 
excesses in eating being injurious. Alcohol should be sparingly used, 
and starchy foods avoided, and animal fats, as far as possible forbidden. 

Harley's method of expelling gall-stones, by manipulation of the 
abdominal walls by the fingers, may be tried for the expulsion of con- 
cretion in the gall-bladder or duct. Lately an operation of the same 
sort has been recommended under the title of " pumping the liver." 
It is performed by making firm and quick pressure on the ribs over the 
liver ; after the pressure is made the hands are suddenly withdrawn. 

Durande's remedy consisted of a mixture of ether and spirit of 
turpentine (3 parts to 2) ; 15 minims of this may be given in cap- 
sules, three times a day, during the intervals between the attacks, or 
every four hours while the attack is on. Turpentine alone appears to 
have some power also of dissolving or causing the solution of small 
calculi. The writer gives it in capsules (10 minims each) for weeks 
at a time in conjunction with the following treatment: 

Alkalies are believed to have a prophylactic effect ; and the most 
popular treatment, and one followed by great benefit, is a prolonged 
course of Carlsbad water or Vichy water before breakfast. Liquor 
potassae (15 minims) bicarbonate of potash (30 grains), phosphate of 
soda (30 grains), castile soap (15 grains), salicylate of soda (20 grains), 
may be alternately tried. 

The mineral acids, especially the nitro-hydrochloric acid (30 
minims), iridin (1 grain), euonymin (1 grain), podophyllin (i grain), 
calomel (1 grain), green iodide of mercury (-J- grain), purgatives, and 
so-called hepatic stimulants, have been given with doubtful success 
with the view of so increasing the amount of bile as to favor the solution 
of the stone. 

The extraordinary successes said to have followed the administration 
of large doses (20 to 40 ounces) of olive oil require confirmation, 
though many reports show that benefit may be derived from doses of 
5 or 6 ounces, taken in divided amounts, over one or two hours. 

The writer has seen large numbers of calculi expelled by one heroic 
dose of calomel (15 grains), followed by a large dose of castor oil. 

Electricity, in the form of the faradic current, with one electrode 
over the gall-bladder, and the other over the spine, has been tried, 
with the view of causing vigorous contraction of the muscular fibres 
of the gall-bladder and its ducts, and in a few cases has been found 
successful. 



270 G-ANGLIOX. 

Where the common duct remains obstructed by a calculus, or where 
the patient's life is rendered unendurable from incessant attacks of 
biliary colic, or where the gall-bladder is found to be distended, or 
where suppuration, ulceration, or perforation, resulting from calculi, 
is believed to be present, surgical procedure is not only justified, but 
may become urgently imperative. 

The operation of cholecystotomy is performed by making a vertical 
incision, 2 to 2J inches long, external to the border of the right rectus 
muscle, commencing one to two inches below the costal arch. This is 
the usual situation of the tumor if present. The point of the tenth 
rib is a good guide in the absence of swelling. Having felt the gall- 
bladder by the finger thrust into the wound (after ligature of all 
bleeding points), its contents are drawn off by the aspirator. The 
collapsed sac is then drawn forward, its walls incised, and their mar- 
gins stitched to the parietal wound, after a thorough exploration and 
evacuation of any calculi in the gall-bladder or ducts. Impacted 
calculi may be removed with forceps or scoop, or they may be crushed 
or broken up with forceps, and the debris washed out with a stream of 
warm water. A rubber drainage-tube is inserted into the cavity, and 
left projecting from the skin wound. After all discharge has ceased, 
the tube may be removed, and the fistulous opening left to close 
spontaneously. 

This operation is safer and more satisfactory than that of sewing up 
the incised gall-bladder, and returning it within the abdominal cavity, 
and it is to be preferred to cholecystectomy, or excision of the dilated 
gall-bladder, as performed by Langenbuch. 

GANG-LION. 

The small, simple ganglions found upon the posterior surface of the 
wrist may be best treated by rupturing their walls, and squeezing the jelly- 
like contents into the neighboring tissues. This is best done by forcibly 
bending the wrist-joint to make the tumor tense, and then, by applying 
strong pressure with one or both thumbs, the ganlion can nearly always 
be ruptured. A smart blow with a blunt instrument may be tried, but 
this is not desirable. If the ganglion cannot be burst with the sur- 
geon's thumb, it is better to insert a fine-grooved needle or slender 
knife-blade, and puncture the cyst, after which the contents may be 
squeezed out. Pressure by a pad of lint and a firmly-adjusted bandage 
generally is all that is required. 

When the tumor returns, a blister may be applied after a second 
evacuation, or the strong tincture of iodine may be repeatedly applied. 
The writer has caused old recurring ganglions to disappear perma- 
nently by folding a coin (a penny) in a piece of lint, applying it 
accurately over the tumor, and bandaging it tightly for several hours, 
taking care that the circulation in the fingers is not seriously inter- 
fered with. 

In large ganglions, especially those containing melon-seed bodies, a 



GANGRENE. 271 

free incision must be made, and the contents thoroughly evacuated 
under antiseptic spray, and a drainage-tube left in until the cavity 
contracts. The old method of slitting up such cysts, and allowing 
them to granulate from the bottom, is not free from serious danger. 
The washing out of their contents with weak corrosive sublimate or 
iodine solutions, and the establishment of thorough drainage under 
antiseptic dressings is preferable. 

GANGRENE. 

The cause of the affection is to be first determined ; should the case 
be one of static gangrene, the immediate attention to the state of the 
circulation is demanded. Thus pressure, whether caused by constricting 
bands (as in hernia), by splints and bandages (as in unskilled surgery), 
or by the pressure of tumors or inflammatory swelling and tension, 
should be, if possible, at once relieved. 

After the removal of the constriction, if the death of the part has 
not already taken place, it may be averted by the application of dry 
warmth, elevation of the limb, and gentle friction or message to empty 
the large venous trunks. 

Swathing of the limb or part involved in several layers of dry cotton 
wool, after friction, should be performed without applying a bandage. 

If the death of the part is beyond question, immediate or speedy 
amputation should be performed, as nothing but evil generally follows 
delay in these cases. The line at which the constriction takes place is 
an accurate limit to the amount of destroyed tissue. 

Traumatic gangrene, if of very limited extent, may be dealt with 
as an ordinary sloughing sore by antiseptic solutions. If the slough 
has not separated, its removal may be facilitated by hot poultices 
sprinkled over with fresh charcoal. 

When a portion of a limb is completely destroyed by traumatic 
gangrene, amputation must follow. It is, upon the whole, safer to 
wait for a line of demarcation. 

In spreading traumatic gangrene, some authorities recommend im- 
mediate amputation, without waiting for a line of demarcation, but 
the weight of authority appears to be against this. It is better to wait 
for some evidence of a limit to the gangrenous process. This is espe- 
cially true if the cause is constitutional. Exception may sometimes be 
made in the presence of a cause obviously local. Every effort must be 
made to keep up the strength and nutrition of the patient to diminish 
tension, and to guard against septic poisoning. 

In gangrene caused by plugging or by ligature of a main artery, or 
by the pressure of an aneurism, amputation may be performed at once, 
without waiting for a line of demarcation. 

In senile gangrene it will generally be found wise not to interfere 
until a well-marked line is formed, the patient's general condition being 
closely watched, and the affected limb enveloped in dry and warm 
antiseptic dressings. 



2/2 GASTRALGIA. 

Hospital gangrene must be promptly met by isolation and thorough 
ventilation, free stimulation, and large doses of iron and quinine. 
Sloughs should be removed, and the affected surfaces thoroughly 
irrigated with warm antiseptic lotions, or cauterized with the actual 
or galvano-cautery, iodine, bromine, or nitric, strong carbolic or other 
acid. The most rigid antiseptic treatment must be carried out. 

GANGRENE OF THE LUNG— See under Lung. 

GASTRALGIA. 

The treatment will resolve itself (1) into the management of the 
case during the attack, and (2) to measures employed in the intervals 
between the attacks. 

Pain may be relieved by opium, and if very severe by hypodermic 
injection of morphine. Cannabis indica sometimes affords prompt re- 
lief. The use of narcotics is, as already mentioned, most objectionable 
in ailments of a chronic nature where there is danger of the opium 
habit being established. In stomach troubles opium, if given in doses 
large enough to affect the cerebrum, always interferes with digestion 
and appetite seriously. Chloral (10 grains), antipyrine (10 grains), 
chloroform or ether (5 minims), nitro-glycerin (1 or 2 minims of a 1 
per cent, solution), bicarbonate of soda (30 grains), oil of peppermint 
(5 minims), oil of cajuput (4 minims), creasote (2 minims), belladonna 
(20 minims of tincture), hydrocyanic acid (4 minims) may be tried 
from time to time. 

The writer has obtained best results from a large dose of bicarbonate 
of soda (40 grains) combined with morphine (& grain). 

Counter-irritation by mustard, hot fomentations, or even iced poul- 
tices may give speedy relief. 

Electricity in the form of the continuous current sent through the 
epigastric region, or of the faradic current applied to the sympathetic 
or pneumogastric, may shorten the attack without resorting to nar- 
cotics. 

Sipping of very hot water may be tried — it often aggravates. 
Acupuncture, or hypodermics of warm water sometimes afford relief. 
Chloroform liniment alone or mixed with the liniment of belladonna, 
or aconite, sprinkled upon lint and covered with oiled silk is a valua- 
ble method of diminishing sensibility. 

For the treatment of the case between the attacks much may be 
done, and the physician should look out for evidence of some organic 
or other affection of the stomach. Pure neuralgia of the stomach is 
a rare disease. Gastritis, ulcer, cancer, dyspepsia, or obstruction of 
the pylorus may be present, and may be the direct or indirect cause of 
the attacks of gastralgia. Appropriate treatment (see under the head 
of each) should be directed to the primary affection. In the absence 
of any stomach ailment save the repeated attacks of gastralgia, treat- 
ment should be directed to the nerve supply of the stomach. Berne- 



GASTRIC ULCER. 273 

dies found useful in the cure of neuralgia in other parts of the body 
have been sometimes productive of great good in gastralgia. Quinine 
in moderate doses (2 grains), gradually increased to 5 grains three 
times a day may be tried with advantage. 

Arsenic in small doses is a valuable drug if given for a sufficiently 
long period. One minim of Fowler's solution before meals in a table- 
spoonful of water should be given for a few weeks, and then 2 minims 
after meals, and so on alternately for three or four months. 

Alum is successful in a considerable number of cases when given in 
doses of about 15 grains three times a day between meals. It appears 
to act in gastralgia somewhat like the way in which it relieves paint- 
er's colic. 

Bismuth in large doses has been given with great benefit in some 
cases, and as much as a quarter of a pound daily has been adminis- 
tered. There does not appear to be any advantage in such heroic 
doses, but half drachm doses of the carbonate will meet all require- 
ments when given four times a day before meals. 

Charcoal given in wafer paper before, or three hours after meals has 
been known to cause the disappearance of the attacks. It can be used 
also when the attack is on, the same remark applies to creasote. 

Salts of silver (J grain of the nitrate and 1 grain of the oxide) may 
be given for short periods. Salts of iron often irritate ; the carbonate 
(precipitated) in 40 grain doses is the best. Salts of zinc, the valeri- 
anate, or the oxide (5 grains) may be tried. Ergotine has been highly 
recommended, but the writer never saw any benefit from it. Iodide 
of potassium (3 grains), binoxide of manganese (5 grains) have been 
also used. Salicin (30 to 45 grains), salicylic acid (20 grains), and 
resorcin (5 grains), appear to act like quinine, and are valuable in 
cases when the neuralgic history is clear. Minute doses of strychnine, 
or nux vomica, are useful adjuncts. Ferments like papain, pepsin, 
pancreatin, and trypsin may be used with advantage as they assist 
digestion, and save some of the work done by the gastric mucous mem- 
brane. They may be employed at the time of the acute attacks, and 
may also be given after or along with meals, while the patient is 
undergoing a quinine, bismuth, arsenic, or other course. Scrupulous 
attention to the quality, quantity, and regularity of diet is an essential 
point. 

GASTRIC ULCER. 

The first indication in severe cases is absolute rest to the stomach, 
both physical and physiological. This is obtained by insisting upon 
the patient keeping the recumbent position, and being fed by the 
rectum. Another essential to obtaining absolute rest to the ulcerated 
organ is the administration of small and repeated doses of opium, 
morphine, or codeine. The nutrition of the body can be maintained 
for long periods by nutrient enamata, and these are necessary in all 
severe cases and whenever hemorrhage is present. 



274 GASTRIC ULCER. 

A nutrient enema should not exceed 5 ounces at the most ; about 
3i ounces is the most suitable bulk. The ordinary beef tea, milk, egg 
and salt enema, thickened with starch, is for the most part absorbed, 
but it is too irritating, and soon sets up an irritable condition of the 
rectum. It may be much improved by adding a teaspoonful of liquor 
pancreaticus to each wine-glassful of enema, and a few minims of 
laudanum to assist its retention. 

Leube recommends the injection of finely divided meat mixed with 
pancreas. Such an enema may be prepared by mixing 4 ounces of 
finely sliced and minutely chopped meat with 1 ounce of chopped 
pancreas and a large tablespoonful of warm water. This may be 
injected through a wide-nozz!ed warm syringe. 

The writer has found that Griffin's nutrient suppositories are excel- 
lent substitutes for peptonized enemata, and possess many advan- 
tages. 

Where the symptoms are of a mild type — hemorrhage, severe pain, 
and persistent vomiting being absent — the patient may be allowed to 
sit up or to cautiously move about, and feeding by the mouth may be 
permitted. 

Solid food, or nourishment containing hard or coarse particles, must 
be strictly forbidden. The diet should consist chiefly of milk. This 
should be administered in very small quantities, and as frequently as 
possible. The success of treatment will to a very large extent depend 
upon the care exercised in feeding the patient. (See directions given 
under Cancer of the Stomach on page 102.) 

Kali or potash water, or lime-water, may be mixed with the milk in 
proportion to the symptoms (acidity, flatulence, etc.) present in each 
case. As the case progresses, good arrowroot, corn-flour, or other 
impalpable farinaceous powder may be cooked with the milk. A little 
later on, sago, tapioca, and ground or well-boiled rice may be given. 
Beeftea, chicken soup, meat juices and jellies, and well-cooked pud- 
dings, free from fruit and spice, can be given. Farola and fine oat 
flour make palatable blanc mange, which can be eaten with renneted 
milk. Any food found to cause acidity must be discontinued, the 
presence of marked acidity having an injurious effect upon the healing 
process. 

As the symptoms disappear and the progress of the case shows that 
the ulcer is probably cicatrized, solid food must be most cautiously per- 
mitted in small quantity, beginning the experiment with well-boiled 
soft white fish, followed up with young chicken, and finally tender 
under-done roast beef, steak, and chop. Alcohol is, as a rule, objec- 
tionable, and sugar should be avoided. 

The different symptoms present during the open stage of the ulcer 
must be met by appropriate remedies. Thus, if hemorrhage occurs, in 
addition to rectal feeding small pieces of ice should be swallowed and 
a compress of ice laid over the stomach. Ergot may be given by the 
bowel, though its value is doubtful. Opium by the bowel is service- 



GASTRIC ULCER. 275 

able, and rarely will acetate of lead and other powerful astringents be 
required. Teaspoonful doses of hazeline may be tried, and turpentine 
capsules are useful. Tincture of iron is of doubtful service, though 
praised by some. Powdered kino is a valuable remedy. (See also 
under Hsernaternesis.) 

Saline purgatives, as Epsom salts, to thoroughly clear out the blood 
which may have passed onward into the intestines, are strongly advised 
by Ord, who emphasizes the importance of thus getting rid of this 
source of great irritation. He combines sulphuric acid with the pur- 
gative, and for the gastric hemorrhage he does not recommend the 
usual astringents. 

Vomiting must be controlled by ice internally, and counter-irritation 
externally, bismuth and hydrocyanic acid, creasote capsules, and small 
doses of morphine. Where milk cannot be tolerated, potash or Seltzer 
water may be added in equal quantity to it. The writer has seen a 
mixture of acid buttermilk and potash water often retained where milk 
was vomited. Rectal feeding may increase the trouble in some cases 
where there is copious acid gastric juice, and the writer has seen vomit- 
ing come on in one chronic case of irritable ulcer every time an enema 
was given ; this is, however, rare. Peptonized milk is disappointing. 

Pain is an indication for perfect rest, blisters, leeching, cold com- 
presses or warm poultices, and morphine. As already mentioned, it is 
a mistake to give morphine in large doses in these cases. It will be 
rarely necessary to give more than T X g- grain, in perule or in solution. 
If the system be brought under the influence of opium, further vomit- 
ing is apt to supervene. 

Atropine, in doses of i a minim of (1 : 100) solution, sometimes 
checks pain and vomiting where opium is badly borne. 

Bismuth, in the form of powder in small doses, acts as a sedative, 
and relieves pain as effectually as it stops vomiting. If given in the 
liquid form it may be combined with hydrocyanic acid and morphine 
thus : 



1& . — Bismuthi subcarb. 
Acid, hydro-cyan. dil. 
Morph. hydrochlor. 
Mucilag. acacise 
Aquse chloroformi (1 : 200) 



• 3ij- 

• 3J. 

• gr- j- 

• 3 V J- 

ad ^ij.-M. 



S. — Take a teaspoonful every three hours ; shake the bottle well. 

In chronic cases Fowler's solution, in doses of 1 minim, relieves pain 
and checks vomiting. 

Charcoal and creasote in capsules are invaluable in such cases. 
Cannabis indica, \ grain of the extract in a minute freshly prepared 
pill, may be tried. 

Carlsbad waters before meals, by neutralizing excessive acid, some- 
times afford considerable relief. Any alkali, or even borax in small 
doses, may be used with the same object in view. 



276 GASTRIC ULCER. 

Pepsin has been said to have caused death by finding its way directly 
into the circulation through the open vessels of the ulcer ; this is highly 
improbable. 

Ord uses the following combination in the treatment of gastric ulcer 
without catarrh — i. e., 20 grains of subcarbonate of bismuth, 10 grains 
of carbonate of soda, and 10 drops of tincture of belladonna three times 
a day. 

When there is much evidence of catarrh he uses what he calls Brin- 
ton's mixture until the catarrh subsides. The following is his formula: 

K. — Potas. bicarb. . . . . . . . ^ij. 

Potas. iodid gr. xxxvj. 

Acid, hydrocyan. dil. . . . . . . Ttl xxxvj. 

Inf. gent, comp ad ,^vj. — M. 

S. — Take a tablespoonful three times a day ; shake the bottle well. 

Blisters are of great benefit in chronic cases. 

Remedies may be tried in chronic cases with the view of acting as 
caustics or stimulants to the ulcerated surface. 

Nitrate of silver, in the form of pill, may be given in doses as large 
as 2 grains. This treatment should not be persisted in. The oxide 
may be given in the same way in doses of 3 or 4 grains. 

Bichloride of mercury (^ grain) and bichromate of potassium (-£$ 
grain) have been tried with but doubtful benefit. Nitrate of uranium, 
in i grain doses, is recommended when the ulceration is believed to 
extend to the duodenum. 

Brinton believed that opium had a very marked influence in causing 
the ulcer to heal. 

In chronic irritable ulcer the washing out of the stomach has been 
recommended. The writer has obtained highly satisfactory results 
from this treatment. The ordinary stomach-pump should not be used 
for this purpose. A soft rubber tube, about one yard in length, should 
be employed. The end introduced into the stomach should be rounded 
off like the tube of the stomach-pump, and a glass funnel should be 
attached to the other end. With this instrument a stream of fresh warm 
water can be poured into the stomach through the funnel raised to the 
level of the patient's face ; by depressing the funnel the fluid is easily 
syphoned off. After the contents of the stomach have been removed 
a stream of weak antiseptic solution — chloroform water (1 : 200) crea- 
sote (40 minims to 40 ounces), boric acid (2 drachms to 40 ounces), 
common salt, and borax (2 drachms to 40 ounces) may be passed 
through the washed organ. Weak Gondy's fluid answers well. 

It is needless to say that the utmost gentleness is to be used, and the 
stomach should not be dilated by the pressure of a high column of the 
fluid. 

Where perforation occurs, and the contents of the stomach find their 
way into the peritoneal cavity, the situation of the patient becomes one 



GASTEITIS. 277 

of the greatest gravity. Absolute rest and opium in large quantity 
may be administered, and all food by the mouth must be stopped, and 
ice applied externally. Such cases nearly always die, though the writer 
has been fortunate enough to witness one permanent recovery, and one 
case which long afterward succumbed to an abscess of the liver and 
empyema. The best treatment is early abdominal incision, washing 
out of the peritoneal cavity with hot water, and the establishment of 
good drainage. (See under Peritonitis.) 

GASTRITIS. 

Unfortunately the term gastritis has been applied by different writers 
to totally different diseased conditions. If we reserve the term acute 
gastritis, for those cases of severe acute gastric catarrh, accompanied 
by serious vomiting, nausea, and depression, the treatment will be that 
already detailed under Ulcer of the Stomach. After remedying the 
cause of the gastritis, i. e., alcoholic excess, indiscretion in food, irri- 
tant poisons, etc., the stomach must get absolute physical and physio- 
logical rest. As the duration of the acute affection is so short, rectal 
feeding will be seldom necessary. In the subacute or chronic forms it 
must be resorted to. Counter-irritation by blisters, sinapisms, dry cup- 
ping, iced compresses, or, where these aggravate the distress, hot poul- 
tices may be applied. 

Opium, by the rectum or hypodermically, or morphine perules, or dry 
morphine placed upon the tongue, are indicated in most cases. Ice may 
be swallowed in very small quantities at frequent intervals, and, as the 
nausea and vomiting yield, milk may be given in spoonfuls. 

Calomel, 5 or 6 grains placed upon the tongue and washed down 
with a spoonful of iced water, may cut short the attack. 

Bismuth, hydrocyanic acid, creasote, or any of the remedies men- 
tioned under Ulcer of the Stomach as useful for vomiting, may be 
given. 

Arsenic, in small doses, has its advocates, but its use is not free from 
danger ; if the symptoms have resulted from an irritant poison, its 
administration may cause serious aggravation. 

The subacute variety may be treated on the above lines. In chronic 
gastritis, the first duty of the physician is to determine, if possible, the 
cause of the affection. Errors in diet, excesses in eating or drinking, 
especially in the use of alcoholic stimulants, should be corrected, after 
which the dyspepsia, vomiting, nausea, pain, gastric tenderness, etc., 
should be treated upon the principles already laid down in discussing 
the treatment of Dyspepsia, Gastric Ulcer, etc. 

Ord lays great stress upon the value of iodide of potassium in gastric 
catarrh, administered with some bicarbonate of soda. It is, in his 
opinion, a drug of inestimable value, and speedily removes simple 
gastric catarrh, and prolongs life in malignant disease. 



278 GENU VALGUM (KNOCK-KNEE) — GLANDERS. 

GENU VALGUM (Knock-knee.) 

Genu extrorsum (out-knee) and bow-leg are deformities owing 
their origin generally to errors in feeding, to malnutrition, and rickets, 
knock-knee being often caused by too much standing or the carriage 
of heavy weights in growing and feeble youth. These affections can 
be, for the most part, successfully treated if the case is seen in the early 
stage before development of the bones has been established. 

The first indication is to insist upon complete rest in the horizontal 
position in bed. The weight of the body must be taken off the yielding 
ligaments and softened bones for a considerable period. 

The nutrition must be improved in every way, and the diet carefully 
seen to. The various measures mentioned under the head of Rickets 
should be applied to those cases coming under that category. 

Massage of the affected limbs should be performed at least twice a 
day. Friction and manipulation, with a view of exerting pressure to 
correct the bending, may be performed by the nurse or parent several 
times daily. 

Bandaging the limbs to suitable splints, selected as sound common 
sense and some surgical or mechanical knowledge may dictate, will 
bring the deformity back to the normal standard when rest and massage 
fail. In knock-knee, a firm cushion of flannel or wool may be placed 
between the knees, and both ankles may be bandaged together. Where 
one knee only is affected, the limb may be strapped neatly and uni- 
formly to a suitable splint, the bony prominences being well protected 
by suitable padding. 

In bow-leg a double-padded splint may be placed between the legs, 
extending from near the perineum to some inches beyond the soles of 
the feet. To this splint both legs should be evenly bandaged. 

It is a good practice to resort to splints, even in mild cases, since 
their use enables the child to be safely carried or driven out in the open 
air without the risk of his leaning his weight upon the limbs. Standing 
should be rendered impossible by the adjustment of the splints. Mas- 
sage may be performed at night. In severe cases attempts may be made 
to straighten the limb under chloroform, and, in confirmed, long-stand- 
ing cases, osteotomy is the only available procedure. 

GLANDERS. 

Stimulants, and abundance of concentrated, easily-digested, sustain- 
ing food, should be administered in all cases of this serious affection. 

The seat of inoculation, when recognized, should be freely cauterized 
by the galvano-cautery. All swellings and local collections of pus 
should be freely incised at an early stage, and the cavities, after being 
syringed, may be well mopped out with creasote and cotton wool on a 
stout probe. 

The free use of antiseptic solutions and inhalations afford the best 
prospects of limiting the terribly destructive inflammation. 



GLAUCOMA. 279 

Drugs are of little avail in the acute cases, but of much avail in the 
chronic forms of the disease. 

Sulphocarbolates rank highest. Twenty grains of the soda salt three 
times a day should have a fair trial. Where there is much prostration, 
large doses of ammonia are indicated. 

Quinine, 5 grains every four hours, dissolved in 15 minims of the 
tincture of chloride of iron, may be giveu. 

Arsenic, iodides, carbolic acid, and strychnine have their advocates. 

Gold has recently reported a bad case which was successfully treated 
by a great number of mercurial inunctions, so as to saturate the system 
with mercury, as in syphilitic treatment. The tumors were opened, 
and the edges of the wounds in some cases touched with the cautery, 
and dressed with antiseptic lotions. 

Symptoms, as they arise, such as pain, diarrhoea, profuse perspira- 
tions, rigors, vomiting, etc., must be met by appropriate remedies. The 
air of the patient's room should be kept saturated with the vapor of 
carbolic acid, terebene, or turpentine, and the greatest care exercised 
against inoculation of the virus on the hands or face of his attendants. 

GLANDS, Diseases of— See Lymphadenitis and Scrofula. 

GLAUCOMA. 

It is just possible that the discovery that eserine or Calabar bean has 
a marked tendency to diminish the tension in glaucoma has not been 
an advantage. Though mild cases of the disease are relieved, and not 
a few permanently cured, by the free instillation of a solution of eserine 
(1 : 250), nevertheless, it may mislead the surgeon by giving a tran- 
sient relief in severe cases, and tempt him to postpone radical or sur- 
gical treatment until the sight is totally destroyed, and the case placed 
beyond the reach of art. 

The severe pain calls for relief, and while awaiting positive evidence 
for diagnosis, eserine may be used. 

Opium or morphine, hypodermically, leeching, and warmth to the 
affected eye, with a sharp purgative of the saline class, will affect very 
considerable relief. It should, however, always be understood that 
such measures are not to be relied upon, save as a means of rendering 
the patient's condition tolerable until marked increase of tension demon- 
strates the serious nature of the affection. 

Belladonna must not be used, from its dangerous power of increasing 
the pressure within the eyeball. 

Of all the operative procedures practised or recommended for the 
relief or cure of glaucoma, there is none which has yielded such satis- 
factory results as iridectomy. 

Iridectomy, to be successful, should be made by a large wound, partly 
in the sclerotic, and not entirely in the cornea, and a large portion of 
the iris, at least one-fifth of the whole, should be removed up to its 
ciliary attachment, partly by cutting and partly by tearing. 



280 GLEET. 

Cocaine can hardly be depended upon to produce the thorough anaes- 
thesia necessary, and ether has the disadvantage of adding to the vas- 
cular pressure. Chloroform should, therefore, be selected. 

Sclerotomy, or the making of a wound in the sclerotic, as if an iri- 
dectomy was about to be performed, has in many cases been successful. 
The knife (Graefe's) should be entered about 2 mm. behind the corneal 
margin. It is, upon the whole, a much less satisfactory operation than 
iridectomy, and often ends in this operation, through prolapse of the iris, 
which must be removed. It is, however, found, in many cases requiring 
a second operation, that sclerotomy may answer all purposes when the 
previous operation has been iridectomy. 

Trephining a circular piece out of the sclerotic behind the ciliary 
region (about the level of the ora serrata) has been practised by Rob- 
ertson. It has not met with much favor, and may end in some cases 
in iridectomy, owing to the adhesions of the periphery of the iris to the 
cornea, which often form in glaucoma. 

Paracentesis of the aqueous humor from the anterior chamber may 
be successful sometimes. 

Hyposcleral cyclotomy, performed by cutting through the ciliary 
body in the antero-posterior direction by a narrow Graefe's knife, has 
some advocates. 

Enucleation, or stretching of the supra-trochlear branch of the fifth 
nerve, may be tried where total blindness exists with glaucoma for 
same months, or should there be much severe neuralgic or inflammatory 
pain in the eyeball or in the region of the orbit. 

GLEET. 

In the treatment of this troublesome affection, which almost always 
has its origin in gonorrhoea, the remedies suitable to gonorrhoea may be 
tried with a fair hope of success. This is especially true of cases coming 
for the first time under notice when there is a history of a neglected or 
badly treated attack of gonorrhoea. Where the disease is of many 
months' duration the ordinary gonorrhoeal remedies are worthless, and 
time need not be wasted in their trial. 

The general health should be improved in every way possible, and 
complications, such as constipation, amemia, dyspepsia, and oxaluria, 
should be corrected by appropriate remedies. Stimulants, excessive 
smoking, sexual intercourse, over-eating, and indulgence in articles of 
food which experience has proved to aggravate the discharge, as tea, 
pickles, beer, etc., must be strictly prohibited. 

Excessive fatigue is as injurious as spending too much time in bed. 
Sea-bathing, when the season permits, or cold baths indoors ond mode- 
rate open-air exercise, are beneficial in all cases. 

Constitutional remedies, as tonics, consisting of full doses of tincture 
of iron (15 minims), with 3 grains of quinine, or teaspoonful doses of 
Easton's syrup, often do good. Tincture of cantharides, in doses of 2 
or 3 minims, is a favorite remedy with many surgeons. The writer 



GLEET. 281 

has no experience of the drug in this disease. He has seen excellent 
results from tonic treatment, with one dose of boric acid (10 grains), 
given at bed-time every night. Turpentine may be used instead of 
cantharides. 

The local treatment of gleet is by far the most important, and the 
number of remedies is almost endless. Nearly every known astringent 
and antiseptic has been injected down the urethral canal for the cure 
of this disorder. 

By far the most successful of all local remedies is the passage of a solid 
silver or plated graduated sound with a wide curve. Sir Henry Thomp- 
son's old-fashioned tapering, solid, heavy bougies are the best instru- 
ments for general use. One of them, well lubricated, should be per- 
mitted to glide into the bladder by its own weight. The size selected 
should be of the full diameter of the urethra ; it should be left in situ 
for a period of a few minutes at first, and this period should be gradu- 
ally lengthened at subsequent sittings and a larger instrument employed 
each time until No. 15 (English) is reached. Any lubricant may be 
used ; the writer uses the glycerin of borax (1 : 6). The present 
official preparation is worthless owing to its fluidity. Most cases of 
gleet will be found to yield to this treatment if carried out for some 
weeks. Twice a week will be about the best rule for guidance as 
regards the frequency of the sittings. The advantage of this treatment 
lies in its freedom from danger when contrasted with the injections of 
strong astringent solutions. Moreover, it effectually remedies any 
stricture or narrowing of the urethra which is found so frequently asso- 
ciated with gleet. The persistent use of the solid bougie, in the writer's 
opinion, will also prevent the formation of stricture. 

Nearly every known antiseptic may be smeared upon the bougie if 
made into a stiff ointment. Special grooved instruments are made for 
the application of solid ointments, but these are unnecessary, as owing 
to the adhesive nature of lanolin,. any substance incorporated with it 
will adhere to the end or curve of the ordinary bougie, and may be 
carried down and left in contact with the diseased area. 

The passage of silver catheters for the treatment of gleet is thought- 
lessly recommended by many authorities. They should never be em- 
ployed as simple dilators ; the solid bougie, being incapable of entangling 
any projecting folds of membrane, should be preferred. 

Iodoform (30 grains), mixed intimately with 1 ounce of Burroughs & 
Welcome's elegant ointment of hazeline, is a valuable lubricant. Car- 
bolic acid, resorcin, nitrate of silver (5 to 15 grains to 1 ounce), 
copaiba, santal oil, iodide of sulphur (5 grains to 1 ounce) may be used 
in this way. 

Where a more complete local application is required the drug may 
be incorporated with a firmer basis, made into bougies, which can be 
passed down the urethra and left to melt by the heat of the body. 
Unna's bougies contain (1 : 100), nitrate of silver, and are made with 
cacao butter and a little wax and Peruvian balsam. Antrophores are 

19 



282 GLEET. 

especially prepared bougies, consisting of sulphate of thallin (2 to 6 per 
cent.). Excellent results are obtained by their use in chronic gonor- 
rhoea and gleet. 

In the absence of these, thallin, iodoform, nitrate of silver, or other 
drug made into a creamy consistence with oil, gelatin, or mucilage, may 
be injected through a soft rubber catheter passed down to the seat of 
the mischief. 

The various urethral syringes may be employed to cauterize any part 
of the canal which is found by Leiter's urethroscope to be diseased. 
Tiemann's or Harrison's irrigators, Guyon's bullet-catheter, or Thomp- 
son's prostatic injector are the best. Twenty grains of nitrate of silver 
to 1 ounce distilled water is the usual strength ; of this 10 to 20 minims 
may be injected, cocaine having previously been injected, and the patient 
should remain afterward in bed for the day. 

Otis treats gleet in the following manner : He first dilates gently 
the urethra to its full extent, without using force ; then a silk coude 
catheter is introduced just beyond the compressor urethrse muscle, so 
that the eye lies in the neck of the bladder, then about 8 ounces of 
fluid injection is introduced into the bladder by a syringe. The patient 
passes this after the withdrawal of the catheter, thus flushing out the 
urethra thoroughly. 

The first injection consists of 1 part each of sulphate of zinc, alum, 
and carbolic acid in 2000 parts. Upon the second day the water is 
reduced to 1500, and upon the third day to 1000, and upon the fourth 
day to 500 parts (1 grain to 1 ounce nearly). Upon the fifth day 
solution of permanganate of potassium (1 : 2000) is used, upon the 
sixth 1 : 1500, upon the seventh 1 : 1000. Afterward the solution is 
changed to one of nitrate of silver (1 : 1000), gradually increased to 
1 : 100. 

If these fail, a few drops of a 5 per cent, nitrate of silver solution is 
passed into the deep urethra by the drop syringe. 
Of injections for gleet the following may be used : 

Sulphate of zinc (3 grains to 1 ounce). 

Nitrate of silver (1 grain to 1 ounce). 

Tincture of iodine (2 minims to 1 ounce). 

Corrosive sublimate (1 grain in 10 ounces). 

Sulphate of thallin (5 grains to 1 ounce). 

Tannin (5 grains to 1 ounce). 

Creolin (5 per cent.). 

Bismuth (30 grains to 1 ounce, with mucilage). 

Acetate of lead (10 grains to 1 ounce). 

Sulphate of copper (3 grains to 1 ounce). 

Iodoform (20 grains in 1 ounce of oil). 

Eucalyptus oil (1 in 30 of oil). 

Sulphocarbolate of zinc (2 grains to 1 ounce). 

Permanganate of potassium (1 grain to 1 ounce). 
Blisters or counter-irritation to the perineum may be useful in some 
cases. 



GLOSSITIS — GOITRE. 283 

GLOSSITIS. 

If the affection arises from mercurial salivation or from iodism, the 
cause must be seen to, and the administration of the drugs stopped. 
Should there be great swelling, threatening suffocation, free linear 
incisions must be made. This course was necessary in a severe case 
under the writer's observation following the bite of a rat. The incisions 
in this case had to be deep, but this is rarely necessary. They should 
be made on each side of the middle line, from behind forward. Leeches 
or minute punctures may be employed where the organ protrudes from 
the mouth. Hot fomentations by solutions of 

Carbolic acid (1 drachm in 12 ounces of water) ; 
Chlorate of potash (3 drachms to 1 pint) ; 
Borax or boric acid (4 drachms to 1 pint) ; or, 
Alum (2 drachms tj 1 pint), afford relief. 

Poultices to the front and the inhalation of moist warm air should 
be tried. 

Saline purgatives or croton oil may be used to cause speedy evacua- 
tion of the bowels. 

As soon as the local symptoms show any formation of pus, a bold, 
free incision should be made deeply into the abscess by a narrow-bladed 
knife, and a warm lotion of permanganate of potash (5 grains to 20 
ounces) should be freely used. 

Syphilitic glossitis yields to small doses of mercury (biniodide), and 
excellent results are obtainable by Heath's method of pickling the 
tongue in mercurial solution. He uses \ grain of the bichloride 
dissolved in 1 ounce of water, and makes the patient hold this in his 
mouth for ten minutes by the watch, three times a day, breathing 
through his nose all the time. He affirms that the result is often 
astonishing. 

GLYCOSURIA— See Diabetes. 

GOITRE. 

The constitutional treatment of goitre will embrace the removal of 
the patient from the district in which the disease is indigenous to a 
healthy locality with a pure water supply. 

Iodine, iodide of potassium (5 to 10 grains three times daily), hydro- 
fluoric acid (10 minims of a J per cent, solution) are the drugs to be 
relied upon. They are occasionally of some use in the soft fibroid or 
parenchymatous forms, but prove useless in the treatment of the cystic 
varieties. It is very doubtful if the hydrofluoric acid is of much ser- 
vice. Sometimes the iodine treatment, combined with change of resi- 
dence and supplemented by local applications of iodine or blistering, 
will effect a permanent cure. 

Local treatment may be tried in many forms, the most innocent of 
which is the daily application of the U. S. P. tincture of iodine. If a 



284 GOITEE. 

decided counter-irritant action is desired, the undiluted liniment (1 : 8) 
may be painted on layer after layer till vesication is produced. 

Iodine ointment may be used instead of the liquid preparation. 
Some surgeons have found better results from the application of a 
weak solution, applied with the view of effecting absorption of the 
iodine. In this case, half tincture and half glycerin or weak spirit 
may be employed, the object being not to injure or destroy the cuticle. 
Ointments of iodides of ammonium, cadmium, and lead have been 
used (1 drachm to 1 ounce) ; they possess no special advantages over 
the pure iodine. 

Biniodide of mercury has removed goitres by the thousand in 
India. It has been of little use in this country. The Indian practice 
is to rub in for ten minutes an ointment consisting of 3 drachms of 
the biniodide to 1 pound of lard. The patient is afterward to sit 
with his goitre exposed to the direct rays of the sun until he is unable 
to bear the smarting. After this some more ointment is gently 
applied, the patient is sent home, and the case seldom requires further 
treatment. 

This method of dealing with goitres might be worth trial during the 
early days of July, when our sun is at his best. 

Blistering with vesicating collodion, combined with internal iodine 
treatment, has given moderate success in soft parenchymatous goitres, 
and may be tried before more formidable remedies are decided 
upon. 

Setons passed through the substance of the gland gave excellent 
results in the hands of Mr. Hey, but the following treatment is less 
dangerous and more efficacious for the soft solid goitre. 

Injection of iodine into the tumor is by far the most satisfactory 
means of reducing the enlargements of soft or moderately firm goitres. 
It is generally useless in the purely cystic variety of the disease, but 
may give good results in the fibro-cystic forms where there is much 
parenchyma present. The writer has seen many successes from this 
treatment in the practice of Sir M. Mackenzie at the Throat Hospital. 
He has tried it himself in cystic goitres without obtaining the least 
benefit. Two grains of iodine dissolved in 25 minims of pure alcohol 
are injected by a hypodermic syringe into the substance of the gland 
twice a week. Some surgeons prefer to inject 10 to 20 minims of the 
U. S. P. tincture. The greatest care is necessary to avoid puncture of 
a large vein, or of the trachea or arteries, and the admission of air 
must be guarded against. 

It is a good plan to compress the superficial veins by tying a piece 
of tape firmly round the base of the neck, below the tumor, before 
inserting the needle. The injection should be made very slowly by 
screwing home the piston, and the needle should never be inserted 
into the same spot in repeating the injections. As a rule, decided 
improvement should be visible in six or eight weeks, even in large 
goitres, though the treatment may be necessary for several months. 



GOITRE. 285 

Generally pain and some tenderness follow soon after injecting, but 
they speedily disappear. 

Osmic acid, iodide of potassium, ergotine, Fowler's solution, and 
absolute alcohol have been used, but without any results warranting 
their selection when iodine is available. 

Electrolysis has been tried in fourteen cases by Duncan with the 
result of six being completely cured. Further experience may prove 
of great value in this method of treating goitre. Continuous applica- 
tion of cold by means of Leiter's tubes has also given some good results. 

When above treatment fails, and the growth threatens to produce 
suffocation, operative measures of a more serious nature may be 
imperatively demanded. Tracheotomy rarely w T ill be of any benefit, 
owing to the nature of the obstruction. Tying of the superior thyroid 
arteries, with the view of starving the growth, is hardly justified by 
results. 

Jones's operation promises to be valuable. It consists in exposing, 
isolating, and resecting the thyroid isthmus. After tying double liga- 
tures on each side near its junction with the lateral lobes, the isthmus 
is removed and the wound well drained and allowed to heal up from 
the bottom. 

By this operation, in the great majority of cases, all pressure is taken 
off the air-passages, and danger to life is averted, and shrinkage of the 
lateral tumors to a considerable extent generally follows. 

Excision or removal of the tumor is a serious operation, but it has 
been performed many times with complete success. Myxcedema may 
be a possible result unless a portion of the gland be left behind, and 
in young subjects cretinism may supervene if the entire gland be taken 
away. 

Removal of the thyroid body by common consent of surgeons should 
only be undertaken under the following circumstances: i. e., when 
pain and dyspnoea threaten to cut life short ; and it should never be 
undertaken with the view of simply removing a deformity. When 
pressure of the tumor causes compression of the trachea, spasm of 
the glottis, or paralysis of the abductors of the glottis, operative inter- 
ference must not be delayed. Fortunately, such events are very rare 
in goitre. 

The operation consists in the full exposure of the tumor by one long 
median incision, and a smaller oblique incision outward and upward on 
each side toward the sterno-mastoid. 

After carefully tying all superficial veins, the thyroid arteries and 
their veins are ligatured and the tumor reflected and enucleated with 
the fingers and handle of the scalpel, the isthmus being divided and 
ligatured before each lateral half of the growth is removed. 

Cystic goitre is best treated by Mackenzie's operation of tapping 
the cyst, injecting 1 to 2 drachms of a watery solution (25 per cent.) 
of solid chloride of iron through the canula by means of a special syringe 
designed to prevent the possibility of the admission of air. The canula 



286 GOITRE. 

is plugged and left in situ for seventy-two hours, after which the plug is 
withdrawn and the contents allowed to flow out. Should the liquid be 
found to contain blood or to show no symptoms of suppuration the injec- 
tion is to be repeated, the plug inserted, and the solution permitted to re- 
main for seventy- two hours more. One injection generally is sufficient 
to establish suppuration, but a second or third may be necessary. After 
pus appears, the plug beiug withdrawn and the canula retained, free 
poulticing should be kept up for weeks. At first, to still further favor 
suppuration, the plug may occasionally be inserted so as to retain a 
quantity of pus for several hours. After this, the cavity should be 
syringed several times a day with tepid water containing an antiseptic 
like boric acid (10 grains to 1 ounce). 

In the subsequent management of the case care should be exercised 
to prevent the canula becoming obstructed. Hovell provides for this 
by inserting a piece of Ellis's spiral silver wire drainage-tube into the 
canula and fixing it there with the extremity projecting into the abscess 
cavity. When the cyst fails to contract, and the purulent discharge 
becomes thin and diminished in amount from flabby granulations, the 
cavity may be daily washed out and a' solution of chlorate of zinc (20 
grains to 1 ounce) he injected and allowed to escape. 

This injection Hovell repeats until he obtains evidence that the 
granulations have assumed a healthy character. 

The canula must be retained in the cyst until its cavity shrinks, and 
if the granulations block up its extremity a shorter instrument can be 
inserted. 

Multilocular cysts may be treated by puncture and injections made 
through the original opening. 

In treating large cysts, it is advisable not to entirely empty their 
contents before injecting, as hemorrhage from their vascular walls 
interferes with the action of the iron. 

Iodine and other irritants have been used, but the above treatment 
is the best for ordinary cases. Small cysts may be dealt with by 
Porter's method, which consists in drawing off the fluid and inserting 
several inches of catgut, previously soaked in tincture of iodine. The 
catgut is allowed to remain until suppuration is established, the canula 
having been withdrawn after its insertion. 

Woakes has recently published some cases of cystic goitre which 
were cured by the introduction of chromic acid into the cysts after 
tapping. If subsequent experience establishes this treatment a great 
advance will be marked in the management of these cases. He intro- 
duces the acid upon a special form of instrument, introduced through 
the canula, and applies it to the walls of the cyst; speedy obliteration 
of the cavity ensued in all his cases. His paper appears in the Lancet 
of June, 1890. 

Free incision of the cyst with suturing of its margins to the skin 
wound, and plugging of the cavity with cotton wool, soaked in anti- 
septic or astringent solutions has given excellent results in some cases. 



GOITRE. 287 

Excision of the cyst in some cases can be done with comparative 
ease, but in others it is a very formidable operation, and one not to be 
lightly undertaken. 

Exophthalmic Goitre. The treatment of this affection is anything 
but satisfactory. Innumerable remedies have been reported as " cur- 
ing" the disease. These remedies in other hands have for the most 
part been found either to produce no good, or to aggravate the evil. 
The symptoms are liable to disappear spontaneously or to subside in 
part for variable periods; this renders judgment upon the value of 
remedies a matter of extreme difficulty. 

Thus iodine has been praised and condemned. Iron has shared the 
same fate, but it would appear that improvement has been frequently 
seen to follow the alternate use of mild preparations of iron and the 
administration of quinine, for periods of about one month each. 

Belladonna, arsenic, chloride of barium, ergotine, and digitalis have 
each some quasi successes recorded, in their favor. Veratrum viride 
has also given temporary relief. 

Recently three cases have been reported as cured by the steady 
administration of 2 to 5 minim doses of strophanthus tincture (1 : 20) 
four times a day, and sparteine (£ grain every four hours) has also had 
an encouraging report. Both these remedies possess the power of 
markedly diminishing the rapid pulse-rate, which is a prominent fea- 
ture in the disease. Further trials of their lasting benefits are awaited 
with interest. 

Galvanism of the cervical sympathic and pneumogastric has given 
excellent results, but no very decided opinion can be formed of the 
permanency of these results in the absence of carefully recorded and 
closely watched cases. Wolfenden has noticed the curious fact that 
the electrical resistance of the body is diminished almost to nothing in 
this disease, a current of a couple of volts passing readily through the 
body, and deflecting the galvanometer needle. 

In applying galvanism to the sympathetic for the relief of exoph- 
thalmic goitre, a weak continuous current (not exceeding ten or twelve 
Leclanche cells) may be used (commencing with half this number). 
The negative electrode should be placed upon the lower cervical spines, 
and the positive moved about upon the skin in front of the sterno- 
mastoid muscles upon each side. The current from four to six cells 
may be applied to the closed eyelids when there is much exophthalmos. 

The writer can report excellent results from the passage of the weak 
continuous current in this manner in a severe case, which is just now 
declared convalescent. His late experiences lead him to believe that 
the only reliable routine treatment will be found to be strophanthus 
internally, and the continuous current three times a week to the brain 
and neck. In applying the current to the brain, he places a pad of 
lint saturated with warm water over the closed eyelid. Upon the top 
of this is placed the ordinary convex electrode. 

Sansom employs the continuous current from twenty to forty Le- 



288 G-ONORKHCEA. 

clanche elements, placing one pole behind the lower jaw, and the other 
at the corresponding point on the opposite side, or at the nape of the 
neck, or just above the sternum. Charcot uses both faradization and 
galvanism, sending the current from the former through both carotid 
regions alternately. The continuous current he sends from the nape 
of the neck through the prsecordium at the third left intercostal space. 
Each sitting lasts ten to fifteen minutes, every other day for six months, 
when a permanent cure may be expected. 

The diet, exercise, free ventilation, periods of rest and sleep must be 
carefully investigated and errors corrected, and everything calculated 
to improve the general health and tranquillize the mind should be 
resorted to. Hutchinson insists upon the importance of a change of 
air to the sea or a mountainous region. 

GONORRHOEA. 

Nearly every physician of experience has his own method of treating 
this disorder. Nevertheless, there are certain broad lines, to travel 
beyond which is dangerous. Can anything be done to prevent, cut 
short, or modify the attack in a patient presenting himself to the sur- 
geon during the period of incubation, before any symptoms of the dis- 
ease show themselves ? The old methods of injecting strong solutions 
of nitrate of silver, and taking large doses of copaiba, are fraught with 
such danger that they have been generally discarded as abortives, 
though some surgeons still advocate their use. Astringent injections 
used at this period are useless, and aggravate the symptoms, which are 
certain to come on with greater intensity after their use, if the gonor- 
rhoea germs have found their way into the urethra. 

The best course to pursue in such a case, if the patient finds he has 
exposed himself to the infection of gonorrhoea, is to begin washing out 
the urethra with a very weak warm injection of some unirritating 
germicide. By far the safest of these is permanganate of potassium. 
Bichloride of mercury may be more certain in its action, but the writer 
has never ventured to use it at this stage, as 1 grain of the perman- 
ganate in 5 ounces of water, made tepid before injection, answers every 
purpose with safety. In those cases where this method of treatment 
fails, the disease when it appears is very mild. The injections to be of 
use must be thorough and frequent, and when any sign of discharge 
appears, the quantity of permanganate is to be doubled. 

In the acute stage of gonorrhoea great harm is done by the injudicious 
use of drugs and injections. Rest, when possible, is of primary impor- 
tance. Diet must be carefully attended to. Milk, with light farina- 
ceous food and eggs, only should be permitted. Animal food, strong 
tea or coffee, and alcohol in every form, must be forbidden. Smoking 
is said to be very injurious. The writer has not, however, satisfied 
himself about this, and, moreover, it is the only solace left to the un- 
happy victim, who is so often tortured with remorse that his state of 
mind reacts upon his disorder. Tobacco may be useful as a mild seda- 



GONORRHCEA. 289 

tive to his irritable and restless state. A sharp saline purge, as 1 
ounce of Kochelle or 4 drachms of Epsom salt, should be administered, 
and repeated daily if necessary. 

Warm baths, when convenient or possible, are of value. 

Thirst may be diminished by copious draughts of effervescing potash 
water, to which fresh lemon-juice is added; the citrate of potash so 
formed being one of the best possible remedies for the irritated urinary 
surface. 

Rarely will aconite, diaphoretics, or febrifuges be called for. But 
in very acute cases, with much fever and great swelling of the penis in 
plethoric subjects, a mixture like the following may be given with 
advantage : 

R. — Antimon. et potas. tart gr. jss. 

Liq. ammon. acet ^ij. 

Tinct. aconiti Til v. 

Aquae carnphorse ad ^yj. — M. 

S. — Take a tablespoonful every two hours. 

Hot or cold water to the penis, whichever gives most relief, may be 
tried, and when in the warm bath the patient may try the effects of a 
warm water injection down the urethra. Unless the case is unusually 
severe or acute, this will give relief. As much Condy's fluid as will 
stain the water may be added, though it will be better for the physician 
to prescribe and injection containing 2 grains of permanganate of 
potassium in 10 ounces of distilled water to be used every hour. 
Copaiba and astringent injections are not to be used until the very 
acute stage is over. 

Chordee at this stage is sometimes a very severe symptom. The 
most reliable treatment is a large enema of warm water, after which a 
suppository like the following may be inserted : 

K .—Ext. belladonna? (U. S. P.) gr. ijss. 

Morphinse hydrochlor gr. iij. 

Pulv. camphorse gr. xl. 

Olei theobromatis gr. lxx. — M. 

Divide the mass into eight suppositories. 

S. — Let one suppository be used at bed-time if the pain is severe. 

Bromide of potassium (20 grains), with 5 grains of camphor and 10 
grains of chloral, may be given when opium and morphine are contra- 
indicated. Cannabis indica, henbane, lupulin, ergotin, monobromate 
of camphor, atropine, tobacco enemata, aconite, and many other reme- 
dies are recommended ; but camphor and opium meet all requirements. 
A nitrite of amyl capsule may be used for inhalation, or in very severe 
cases a 2 per cent, cocaine solution may be injected. 

Upon the subsidence of feverish symptoms and the diminution of 



290 GONORRHCEA. 

pain in micturating and chordee, the stage for internal anti-gonorrhoeal 
remedies and astringent injections has arrived. 

Of all internal remedies, new and old, copaiba stands at the head, 
notwithstanding its disgusting flavor. Capsules do much to mask 
this, but the odor of the eructations is sometimes very annoying. 
Emulsions are very liable to upset the stomach. Cubebs may be easily 
combined with it, though some prefer to give the powdered cubebs 
alone in milk. 

The following is by far the best means of prescribing copaiba : 

R • — Pulv. cubebae ^ij. 

Pulv. potassii nit gij. 

Pulv. Doveri gss. 

Bals. copaibse . . . . . . . . q. s. 

S. — The size of a hazelnut to be taken in wafer paper, three times a day, two 
hours after meals. 



The following mixture may be order 

R . — Bals. copaibse 
Liq. potassse 
Mucilag. acacise . 
Spt. setheris nit. 
Aqu?e cinnamom. 



ed: 



3iij- • 

3iij- 

.5 vss.— M. 



S. — Take a tablespoonful four times a day after meals. Shake the bottle. 

Santal oil acts like copaiba, and is less likely to be followed by the 
eruption which sometimes follows copaiba. It may be given in a 
paste or electuary, in capsules, or in a mixture. Twenty minim doses 
after meals, three or four times a day, may be administered. It is much 
less unpleasant and less likely to upset tbe stomach than copaiba or 
cubebs. 

Tincture of cantharides has been highly recommended in this, and 
even in the acute stage when there is pain in micturition and chordee ; 
1 minim may be given every three hours. It is a remedy which, the 
author has never tried and does not intend to try. 

Piper methisticum, pulsatilla, buchu, arbutin, benzoic acid, hydras- 
tis, thaliin, salol, turpentine, hazeline, Canada balsam, and many other 
remedies have their admirers and advocates, but the above-mentioned 
will be found to fulfil all requirements. 

Tincture of iron is a drug of unquestionable value in some cases, 
and it may be given in every case at the end of the balsam treatment, 
which generally lasts about fourteen to twenty-one days. During the 
administration of copaiba, cubebs, or santal oil, should any indiscre- 
tion in diet or exercise cause a relapse to the feverish chordee, or pain- 
ful micturating stage, these remedies should be stopped till the acute 
symptoms pass off. 

Locally the stage of free discharge and comparative freedom from 



GONORRHCEA. 291 

pain is very generally treated by means of astringent injections at the 
same time that the patient is having the balsam internally. The 
favorite injection with the writer at this stage, and at every stage of 
gonorrhoea, is the permanganate of potassium ; in the early stages, as 
already mentioned, the solution should be weak (J grain to 1 ounce). 
At the stage under discussion an injection may be ordered containing 
1 grain in each ounce of distilled water, with directions that at first it 
is to be diluted with an equal volume of warm water before injecting. 
The quantity of water is to be diminished each day until the full 
strength of the injection is used. All urethral injections should be 
used tepid or warm, and it will suffice for all ordinary purposes if the 
patient keep a small bottle of the fluid in his trousers' pocket, where 
it soon becomes of the same temperature as the body. 

The urethra should be first well washed out with a stream of warm 
water after micturating, when 2 or 3 drachms of the solution should 
be injected slowly down the urethra/and its return prevented by grasp- 
ing the head of the penis firmly between the fingers for two or three 
minutes. The frequency of the injections will depend upon the nature 
and strength of the solution and the peculiarities of the case. As a 
rule, it is much better to inject a weak solution frequently than a 
stronger one less often. It is one of the many virtues of the perman- 
ganate solution, that there is little danger in overdoing it in this 
direction. Little or no smarting should follow its use after a few trials, 
and, if smarting result, the injection should be diluted. 

The writer believes that the successful treatment of gonorrhoea by 
injections depends, upon the Avhole, much less upon the nature of the 
injection than upon the skill of using it. He would, thereforo, ven- 
ture to suggest to the young practitioner the advisability of selecting 
one drug and adhering to it persistently, varying its strength and 
altering the frequency of the injections according to the effect desired 
or produced. By these means he soon becomes master of the remedy, 
and he will be astonished to find how T much he will be able to do with 
it, and how easily he can alter its effects to suit the constantly chang- 
ing conditions of the diseased state. The endless varieties of injec- 
tions tempt the physician to change from one to the other, to the 
detriment of the patient and to the deterirration of his own experi- 
ence. This principle applies to every department of treatment, and 
is one of the secrets of the success of some physicians, whose conserva- 
tive prejudices have prevented them from trying most of the new and 
worthless drugs daily written up in the current literature of medicine. 
The man w T ho is patron of all drugs will too often be found not to be 
master of a single remedy. 

Bichloride of mercury is an excellent local remedy in gonorrhoea, 
and, possibly, it is the best of all. The writer has had little experi- 
ence of it in this disease however, because since he has adopted the 
practice of using the permanganate, he has scarcely ever found it fail to 
do all that could be desired of it. The strength of the solution may be 



292 GOKORRHCEA. 

varied to suit the stage and severity of the affection. As a rule, an 
injection containing J grain in 16 ounces of water is a safe solution to 
begin with. This is 1 in 14,000, and may be injected warm every hour 
or two hours. In three or four days the strength may be gradually 
increased until twice this proportion of the bichloride is employed. 

The physician can order 1 grain to be dissolved in 16 ounces of 
water, with directions that this is to be diluted, at first, with an equal 
quantity of hot water, the water to be gradually diminished until the full 
strength is employed. The salt should not be increased above 2 grains 
in the above quantity of water (i. e. 1 : 3500). It is speedy, safe, and 
certain in its action, and has been found equally efficacious in the 
specific and in the non-contagious forms of urethritis. 

Salicylate of mercury, 1 grain in 4 or 5 ounces of water, has been 
greatly extolled. 

Sulphate of zinc is by far, the most frequently employed injection 
in gonorrhoea. It is used in strengths varying from 1 to 5 grains in 
each ounce of water. The latter proportion is too great for safety, as 
it is liable to produce pain and aggravation of the symptoms, as well 
as to induce epididymitis. Any strong solution may bring about this 
latter complication. 

Acetate of zinc (2 to 3 grains to 1 ounce). 

Chloride of zinc (J to 1 grain in 1 ounce). 

Sulphocarbolate of zinc (2 grains to 1 ounce). 

Carbolic acid (6 grains to I ounce). 

Chloral (2 grains to 1 ounce). 

Boric acid (10 grains to 1 ounce). 

Nitrate of silver (i grain to 1 ounce). 

Acetate of lead (3 grains to 1 ounce). 

Tannin (5 grains to 1 ounce). 

Alum (3 grains to 1 ounce). 

Creolin (6 per cent.). 

Iodoform (10 grains to 1 ounce). 

Chloride of iron (1 minim of the strong liquor to 1 ounce). 

Decoction of lemons. 

Citric and salicylic acids (2 grains and } grain). 

Kecord's injection of sulphate of zinc and acetate of lead (5 grains 

each to 1 ounce). 
Ichthyol (1 per cent.). 
The above are but a few of the many drugs employed for the local 
treatment of gonorrhoea ; the zinc salts are the most satisfactory. 
The nitrate of silver is objectionable owing to the pain it causes, but 
in dilute solution it has again become fashionable, and Continental 
practitioners are usiug it largely. About 1 grain in 6 ounces distilled 
water is a good working strength. 

As mentioned under gleet, bougies called antrophores, consisting of 
a solid soluble gelatine basis, containing 2 to 5 per cent, of thallin, 
the whole enclosed in a fine nickel-plated spiral, are now largely em- 



gout. 293 

ployed in the treatment of gonorrhoea. They are inserted into the 
urethra and left in situ. Solid bougies, made up of a similar basis 
and containing iodoform and eucalyptus, are employed in the same way, 
and nearly every drug mentioned above has been used in this form. 

For complications, see under rheumatism, conjunctivitis, orchitis, 
cystitis, etc. 

Gonorrhoea in women is to be treated upon the same lines, and the 
disease rapidly yields to permanganate solution, 5 to 10 grains to the 
pint. The only point worth remembering in these cases is that the 
vagina should be well washed out with at least a quart or three pints 
of warm water before injecting. As the discharge lessens, sulphate of 
zinc (1 drachm to the pint) may be used, but upon the whole the best 
routine treatment will be found in a mixture of equal parts of pow- 
dered alum and borax, of which a tablespoonful may be dissolved in 
three pints of warm water, and injected when nearly cold three or 
four times a day, after washing the passage out with warm water. 

When cystitis supervenes, the remedies mentioned upon page 66 are 
to be resorted to. Medicated pessaries, containing iodoform, carbolic 
acid, creolin, resorcin, ichthyol, and other antiseptic are both conve- 
nient and efficacious. 

GOUT. 

The treatment will embrace the management of the case (1) during 
acute attacks ; (2) between the attacks ; (3) during the chronic stage. 
The diet in acute or transient gout should be chiefly liquid, no solid 
animal food being permitted. After the first day, farinaceous pud- 
dings, eggs, weak beef tea, and chicken soup may be given. Concen- 
trated beef essences may be allowed if the attack is occurring in a 
broken down constitution. 

Two systems of managing gout have been tried, one consisting of 
administering large draughts of hot or warm water, alternating with 
quantities of weak soup ; the other is known as the " dry cure," and 
consists in the administration of dry food, like hard biscuits, without 
any liquids at all. Neither exclusive method of treating acute gout 
has been followed by results justifying further trial. Where the 
attack is occurring in a young or middle aged strong subject the aim 
should be to feed him upon as low a diet as possible consistent with 
safety, milk, barley-water, weak arrowroot, toast and water being 
given freely. In those of weak constitutions, the aged, and those who 
have suffered from previous attacks, this treatment must be modified 
considerably, a fairly generous allowance of food being given with as 
little nitrogenized element as possible. 

Stimulants must, unless in very exceptional cases, be forbidden. 
In the presence of debility or intemperate habits, alcohol in limited 
amount is called for, and then wines of all kinds are contra-indicated. 
A moderate quantity of good old whiskey is by far the most suitable 
stimulant in these exceptional cases. Next in value to it will come 



294 gout. 

good brandy and pure gin, and the stimulant should be combined 
with the food, whiskey or brandy and milk making an acceptable 
beverage, while gin may be given after food with an effervescing 
liquid. 

As the attack passes off the diet may be improved, fish, fowl, oysters, 
and vegetables being permitted. 

Medicinal treatment at this stage will consist of one smart saline 
purge and the administration of colchicum. About the value of this 
drug in gout much has been written, and many strongly insist upon its 
numerous bad qualities, and affirm that it should never be given, as it 
causes the disease to return and show itself in worse forms, and that its 
administration is liable to cause the mischief to fly from a safe region 
to a vital organ, etc. Garrod, Yeo, Roberts, Bartholow, and, indeed, 
most of the best modern authorities, recommend the remedy as a specific, 
and there cannot be any danger in using it in moderate doses under 
strict and close surveillance. 

There are several methods of administering colchicum in acute 
gout. All authorities agree in one point — viz., that purging by the 
drug is not necessary, and that vomiting caused by it is highly objec- 
tionable. It is never advisable to produce the physiological effects 
of the drug in treating this disease. Called to a patient in an attack 
of gout, 25 minims of the wine may be given at once, and 8 minims 
every four or six hours afterward. It will be safer to give 15 minims 
at first, and 5 minims every hour for six or eight doses until pain is 
relieved in very smart attacks. The drug may be given with advan- 
tage in combination with alkalies, or in effervescent mixtures contain- 
ing bicarbonate of potash, which can be given with lemon-juice or as 
the white mixture. 

R. — Vini colchici giij. 

Magnesii sulph. . . . . . . |jj. 

Magnesii carb. ^ij. 

Aquae menth. pip ad ^xij. — M. 

S. — Take half a wineglassful every four hours. Shake the bottle. 

Where there is much prostration, saline purges and the above mix- 
ture are contra-indicated. In such cases a dose of rhubarb and colo- 
cynth pill, or ^ grain of podophyllin, may be given with advantage. 

Opium, chloral, and morphine may be used for the relief of acute 
pain. If possible, it is better to avoid these remedies and trust to local 
treatment, but where the agony is intense the hypodermic injection of 
morphine must be resorted to. Hyoscyamus, belladonna, or atropine 
will generally prove of little value. 

Where diuretic and diaphoretic action is required — viz., where there 
is a scanty quantity of urine and a hot, dry skin — the colchicum may 
be replaced by 3 grains of citrate of lithia in 5 ounces of potash 
water and a little lemon-juice every hour for four doses, then every 



gout. 295 

two or three hours. Elimination of uric acid by this means is speedy 
and beneficial. 

Sleeplessness is best relieved by 20-grain doses of sulphonal or large 
doses of the bromides. 

Salicylate of soda has of late years been much used in the treatment 
of gout, instead of colchicum, and it has been demonstrated that it 
assists the elimination of. the excess of uric acid in the blood, it dimin- 
ishes fever, and relieves pain. It may be given in doses of 30 grains 
at the beginning of the attack, and repeated every four hours in half 
this amount. The writer has seen most satisfactory results from its 
administration in acute gout. 

The local treatment of acute gout resolves itself, for the most part, 
into the use of remedies for the relief of pain. In those cases where 
the pain is " bearable," the best course to follow is to place the affected 
joint in a position of absolute rest, surround it with thick layers of 
warm and dry absorbent wool, covered in by a piece of thin mackintosh, 
the whole being evenly and lightly bandaged, and placed upon a pillow 
in a slightly elevated position. The wool should be changed every 
twenty-four or forty-eight hours, and a fresh, dry, warm supply 
applied. 

Leeching invariably does some mischief. Poulticing is also objec- 
tionable, and cold lotions or compresses may cost the patient his life, 
and arnica never should be employed. The application of a strong 
solution of nitrate of silver appears to act beneficially only by substi- 
tuting one form of misery for another. A very hot foot-bath of warm 
fomentation of poppy capsules and chamomile flowers gives some relief. 
A piece of flannel wrung out of hot water and sprinkled over with 
liniment of belladonna or aconite may be tried. These liniments or 
chloroform liniment may be applied upon lint and covered over with 
oiled silk, or the joint may be smeared over with the extract of bella- 
donna rubbed into a cream with glycerin. Veratrine or aconitine 
ointments, oil of peppermint, tobacco leaves, lotions containing cocaine, 
chloral, iodide of potassium, iodine, salicylates, lithia salts, cajuput 
oil, iodoform, alkaline solutions, solutions of morphine and atropine 
(2 grains and 1 grain to each drachm), spirit lotion, and ether and 
w T ater, have been used with various intentions and varying successes. 

Blisters have been used. Their beneficial effects are best seen in 
some cases of chronic or irregular gout. 

Where the attack is interrupted by the appearance of symptoms 
characteristic of suppressed, retrocedent, or irregular gout, the principles 
embodied in the previous remarks are to be carried out. The first 
point to attend to in such cases is to induce a rapid and immediate 
elimination of the poisonous material in the blood by the kidneys, skin, 
bowels, or certain joints or tissues. Colchicum must be used in such 
cases with unusual circumspection, purely eliminatory treatment being 
more reliable. Symptoms of collapse following the invasion of the 
vital parts, as the heart, nervous system, or stomach, must be met by 



296 gout. 

general stimulants and free counter-irritation of joints which have been 
known as the former local indicators of gout. This can be done by 
very hot fomentations with mustard and water, turpentine stupes, 
cayenne, liquid blisters, or local or general hot packs. 

The treatment of the disease during the intervals between the attacks, 
or in the period succeeding a first attack of gout, should be directed to 
the prevention of further attacks or the prolongation of the intervals, 
and the removal of local remnants of former joint troubles. 

With these objects in view, every surrounding and habit of the 
patient's living must be inquired into and scrutinized, and the most 
rigid rules laid down for his guidance, especially should he be the 
victim of a strong hereditary tendency. 

Everything that can possibly increase the abnormal formation of uric 
acid in the system is to be forbidden or corrected, and every measure 
which in any degree increases, stimulates, or assists in the elimination 
of this product after its formation is to be encouraged. 

Diet, next to heredity, is the most potent factor in producing gout. 
Conflicting opinions prevail upon the advisability of eliminating cer- 
tain articles of food, but all authorities are at one in condemning general 
gourmandizing or excesses in eating. The very large surplus which 
the majority of mankind pushes down the throat -over and above what 
is really necessary to maintain life is not to be cut completely off, but 
the victim of gouty tendencies is certainly called upon to very materially 
diminish this surplus. Obesity is what he should dread, though he may 
partake of fat and butter freely. 

Animal food in ordinary amount is condemned by most writers. 
This is certainly a mistake, as it is curtailed in the ordinary dietary for 
gout to make way for a larger than usual amount of farinaceous and 
starchy material, which is decidedly more objectionable than butchers' 
meat. Underdone roast meat and steak or chops may be freely allowed, 
while fish and poultry are unobjectionable. 

The accessory dishes are the source of danger to the gouty. Pastry, 
sugar, puddings, entrees, pork, game, sweets, fruits, and especially 
starches, are to be avoided. According to Draper, the cardinal feature 
in the gouty diathesis is the feeble capacity for the digestion and 
assimilation of carbohydrates and their derivatives, and this afibrds 
the guiding principle for the regulartion of the gouty dietary. 

Some physicians, looking to the dangers of the formation of uric 
acid from a purely nitrogenous or meat diet, exclude it entirely, and 
the patient turns to a food chiefly made up of starches. Both extremes 
are very objectionable, and of the two, probably the starchy diet is the 
more objectionable, though the writer has witnessed serious results 
from the Salisbury diet of beefsteaks and hot water. Milk, butter, 
cream, fats, cheese, and vegetables in fair amount, and celery and 
salads may be freely permitted. Potatoes are objectionable. Water 
should be very freely used as a beverage. 

About wines, beer, and all fermented liquors, there can scarcely be 



gout. 297 

a doubt that all are objectionable, and should be strictly avoided. It 
will, however, be found that this rigid rule will be resented by most 
patients, and it becomes the painful duty of the physician to express 
an opinion about the least objectionable member or members of this 
group. This is no easy matter. Although all authorities condemn the 
entire group, nearly every one of them is permitted as the least objec- 
tionable tipple by some authority. 

Thus, good old port is even advocated by some physicians. Roberts 
says that " the most suitable are good claret, Hock, Moselle, Chablis, or 
Sauterne, and good dry sherry suits some gouty patients well." The 
writer has seen this latter wine, "good and dry," become the sole cause 
of bad gout in a patient who never took any other form of stimulant. 
It is almost better to insist upon all and each of these being decidedly 
injurious, and leave the responsibility of nominating his own poison to 
rest upon the unfortunate victim. Poor human nature soons twists the 
doctor's opinion of "least objectionable" into a decided "permit," and 
excess is the common result. 

Where an alcoholic stimulant is deemed necessary, there can be 
no doubt about the best. Whiskey, brandy, or gin, well diluted 
with an alkaline effervescing water, and always given along with or 
immediately after food, is, from the gouty point of view, almost free 
from objections. 

In gouty patients sometimes one excess in the use of fermented 
liquors will bring on an attack, and in some an attack may follow 
one excess in eating. The lesson to be enforced, therefore, is tem- 
perance in all things. Some authorities insist upon the fact that it is 
the quality, and not the quantity, which is injurious. There is no 
doubt that inferior wines are poisonous to the gouty patient, who can 
sometimes indulge in really good wine without suffering from it. 

Exercise comes next in importance to diet as a factor in the treat- 
ment of gout, though if the writer judged entirely from his own limited 
experience in gout, he would say that he has observed much more 
mischief to follow want of muscular exercise than to supervene upon 
errors in diet. Free open-air exercise (the best form being smart 
walking) should always be insisted upon. It should be pushed to the 
extent of fatigue, and one long walk, endiug in moderate " tiredness " 
and a fair amount of perspiration, is a daily remedy of great efficacy 
in the treatment and prevention of gout. Mere moving about in the 
open air, as most members of the upper classes do, will not suffice, and 
the class of patients generally afflicted with gout do not relish smart 
walking. If the patient be not too old, he should be advised to try an 
outdoor game, like golf. 

Horse exercise is very beneficial, and may be freely indulged in by 
those whose physical condition permits of it. 

Indolent habits are to be given up, early to bed and early to rise 
being the motto. Many instances are to be met with where confirmed 
gout in middle-aged subjects, which had resisted all treatments, has 

20 



298 gout. 

disappeared upon seme reverse of fortune which necessitated the 
abandonment of all luxurious habits, and compelled the victim to 
lead an active and useful life. Freedom from worry or excessive 
brain strain is desirable ; but honest, hard work, mental or physical, 
is a good antidote. It is, of course, impossible to carry out these 
principles in chronic invalids suffering from gouty joints and other 
locomotive disabilities. For them massage is a boon if persistently 
employed. 

Sea or cold bathing for the vigorous, or wet packs daily for the 
crippled are highly beneficial. The Turkish bath is to be recom- 
mended with caution. Change of air is beneficial if carried out with 
judgment, a dry, warm, or temperate atmosphere suiting most cases in 
the winter, the sea being avoided, especially where there is a tendency 
to skin troubles. Many resorts are sought out by gouty patients where 
a course of alkaline mineral waters can be had ; of these the best is 
Carlsbad. The great value of drinking of warm alkaline water has 
been long recognized in its property of preventing attacks and of re- 
moving renal, hepatic, and nervous disorders resulting from gout. In 
the opinion of most competent authorities as Garrod, Ebstein, Le Clerq, 
etc., the alkaline mineral waters exert their beneficial effects through 
their action upon the liver and alimentary canal. The Carlsbad gout cure 
embraces more than merely sipping the water ; exercises, bathing, diet, 
and other matters are carefully attended to. At home, Bath, Chelten- 
ham, Leamington, Buxton, Harrogate, and Strathpeffer may be ad- 
vocated, and the baths, with the internal use of the waters, tried for 
some months. 

Kissingen, Vichy, Homburg, Royat, Baden-Baden, Wiesbaden, 
Nauheim, and Aix-les-Bains are favorite resorts for gouty patients 
who do not mind the journey. 

The waters imported from many mineral springs are in constant use, 
and the best of them are Friedrichshall, Hunyadi Janos, and Vichy. 
Contrexville water, to be of use, must be taken as it is at the spring 
in very large doses. About one gallon per day is not a very high 
average amount for the gouty or calculous patient to consume. Sir 
W. Roberts has stated, as one of the conclusions from his valuable 
researches on gout, that a patient verging upon an attack of gout 
should not take mineral waters rich in soda or lime. 

The medicinal remedies available in the treatment of gout, either 
with a view of preventing attacks or of removing local manifestations 
of the disease, will embrace the use of remedies whose action will be 
chiefly exerted upon the eliminatory organs. 

Alkalies, by forming soluble salts with uric acid, which salts 
acting as diuretics, are freely washed out in the urine, cause marked 
elimination of uric acid, and are the most valuable of gouty 
remedies. 

Potash salts in full doses (20 grains of the bicarbonate four times 
a day or of the citrate) are preferable to the corresponding soda 



gout. 299 

salts, because the urate of potash is more soluble than the urate of 
soda. 

Lithium forms very soluble salts with uric acid, and is much valued 
as a remedy in the subacute attacks of gout. 

Carlsbad salt and other alkaline springs act in the same way. 

Salts of the alkaline earths act in a similar way, and the lime and 
magnesium waters are much prized by some physicians. 

Disorders of the stomach, liver, bowels, and kidneys are to be met 
by appropriate treatment directed to these organs. 

Salicylic acid, or the soda salt, is given with the view of assisting in 
the elimination of uric acid. Very divergent views are expressed upon 
the subject. Germain See, Lecorche, Lathum, and others testify to its 
great value either as a means of causing elimination of uric acid, or as 
a powerful remedy capable of preventing the formation of uric acid in 
the system. 

Though it does not appear to really cut short or cure the disease, it 
is of great value in relieving the urgency of many of the symptoms, 
especially the cardiac and pulmonary distress. The proper indica- 
tion, therefore, for the exhibition of salicylates would appear to the 
writer to be during the attacks of acute or chronic gout, and not in 
the intervals. 

Benzoates, either in the form of benzoic acid or the benzoates of 
sodium and lithium, have been much used as preventives or cures for 
gout. Beyond their diuretic action, there is not much encouragement 
to be found in perusing the clinical reports of cases where they had 
been extensively tried. 

Phosphate of ammonia is a remedy of very considerable power in 
preventing attacks of acute gout, and if given in doses of 10 to 20 
grains for long periods in solution, well diluted, it is of great benefit 
in chronic gout. Haig insists upon the great value of a course of pure 
phosphate of soda in the chronic forms of gout, and in the intervals. 
Chloride of ammonium acts in much the same way. It is indicated in 
the intervals between the attacks of acute gout, especially where neurotic 
troubles remain as evidence of the presence of uric acid still in the 
system. 

Iodide of potassium is of great value in chronic gout, or in the in- 
tervals between acute attacks. When there are renal or vascular 
complications there is no remedy to equal it, and it is also of great 
service in the treatment of local joint trouble in the chronic forms 
of the disease. The writer has given it in such cases with benefit, 
combined with alkalies and a small amount of colchicum. 



K . — Potassii iodidi 



Potassii bicarbonatis 

Vini colchici 

Aquae eamphorse 

S. — Take a tablespoonful in a wineglassful of water, three times a day after 
meals. 



3ij- 



3ij- 
^xij.— M. 



300 GOUT. 

Free iodine has been much praised by some practitioners, but it has 
not found much favor. 

Guaiacum may be used with advantage in doses of 5 grains three 
times a day. It is indicated in the more chronic forms of the disease 
where the painful condition of the joints appears to be almost constant. 
Garrod speaks in the highest terms of it in such cases. Where the 
affection closely simulates chronic rheumatism it is most useful. -The 
Chelsea pensioner (see author's work on Materia Medica and Therapeu- 
tics, fifth edition, page 430) is a famous electuary, containing in addi- 
tion to guaiacum, sulphur, rhubarb, mustard, and nitre. It may be 
given in doses of one teaspoonful morning and night. 

In chronic gout the disease has become so thoroughly established 
that when the patient is not suffering from subacute attacks, he is 
groaning under constant complications of an arthritic, renal, neurotic, 
asthmatic, cardiac, or cutaneous nature, which may render life almost 
unendurable. The guiding principles for the treatment of such cases 
are those just discussed. Diet, exercise, baths, alkaline waters, purga- 
tives, colchium, iodides, alkalies, change of climate, benzoates, guaia- 
cum, arsenic, iron, tonics, massage, warm clothing, salicylates, etc., are 
to be carefully weighed, and their proper and judicious selection de- 
cided upon the special features of each case. Treatment directed to 
the local troubles, or complications, is to be based upon the general 
principles mentioned under the heading of the part affected. The two 
great points in treatment of every stage of gout are to be emphasized 
here, viz., diminished formation of uric acid and increased elimination. 
The latter consideration will suggest the closest attention to renal func- 
tions. The concretions of urate of sodium existing in the neighbor- 
hood of joints are not to be lightly meddled with. Since they are for 
the most part isolated from the blood by non-vascular tissues the or- 
dinary remedies used for their removal as alkaline lotions, weak elec- 
tric currents, liniments, friction, massage, blisters, etc., are seldom of 
much use. Unless wheu interfering considerably with comfort or the 
action of joints, the limb may be best treated by continuous, dry 
warmth. Where a necessity exists for their removal, the skin may be 
incised and the mass turned out. This is seldom necessary. Edison, 
of New York, has demonstrated that gouty concretions may be dimin- 
ished to a remarkable extent by the application of electrical endos- 
mosis. 

For the most scientific and comprehensive account of the treatment 
of the uric acid diathesis, the reader is referred to an address deliv- 
ered by Professor Burney Yeo before the section of therapeutics, 
under the presidency of the author, at the meeting of the British 
Medical Association in 1887. The address and discussion following 
are published in the British Medical Journal of January, 1.888. 

GRAVEL— See Stone in the Kidney and Stone in the Bladder. 
GRAVES' DISEASE— See Goitre Exophthalmic (page 287). 



HiEMATEMESIS. 301 

GUMS, Spong-y— See Stomatitis. 
GUNSHOT WOUNDS— See under Wounds. 

H^3MATEMESIS. 

The majority of cases will be found to be associated with gastric 
ulcer, and the question is dealt with in speaking of Gastric Ulcer 
(page 274). Absolute rest in the horizontal position, and physio- 
logical rest to the stomach, as far as possible, should be maintained. 
Ice, swallowed in small pieces, should be the only substance permitted 
to enter the stomach. In severe cases, stimulants, food, and even 
medicines must be administered by the bowel. 

Externally, iced compresses in thin subjects, and dry cups and 
smart sinapisms, where the abdominal walls are thick, may be em- 
ployed in severe cases. Hot foot baths, with or without mustard, tend 
to diminish hemorrhage by acting as revulsants. 

Opium or morphine, given as a suppository or by hypodermic 
injection, arrests peristaltic action in the stomach, allays nervous ex- 
citement, and calms the circulation, putting the patient into the most 
favorable conditions for recovery. A little morphine (} grain) may 
be placed upon the tongue and washed down with a teaspoonful of 
iced water, but, as a rule, it is well to avoid administering drugs by 
the mouth except in urgent cases, as their presence often aggravates, 
by exciting increased peristalsis and vomiting. 

Where it is decided to give hemostatic remedies, ergotine may be 
administered, subcutaneously, in the form of the hypodermic solution 
(1 : 3), in doses of 1 minims every three or four hours. 

Where these measures fail, styptics may be tried by the mouth, and 
the following may be used= They are enumerated in the probable 
order of their merit. 

Tannin, given dry in wafer paper or in solution, 10 grains in iced 
water every two hours. 

Chloride or nitrate of iron or sulphate of iron. The weak solution 
of the chloride, in 30 minim doses in iced water, is the least objec- 
tionable. 

Acetate of lead, in doses up to 5 grains, may be administered in 
solution every two or three hours in severe cases. It is useless to order 
it in the pilular for hemorrhage from the gastric membrane ; and 
acetate of lead, when given in the form of pill, should always be 
freshly prepared, as it is liable to become hard and insoluble when 
kept in the pilular form for any time. 

The following is a useful formula for gastric or pulmonary hemor- 
rhage : 

B:. — Plumbi acetatis ^j. 

Acid, acetici dil £> jss. 

Morphinse acet gr. jss. 

Aquae dest ad ifviij. — M. 

S. — Take a tablespoonful with a little water every two hours. 



302 HJEMATIDEOSIS. 

Aluin, in 10 grain doses in solution every thirty minutes, sometimes 
proves successful. In large doses it is emetic. 

Gallic acid maybe tried in doses of 5 to 10 grains, and some believe 
it to be more efficacious than tannin ; this is not likely. It may be 
combined with sulphuric acid with advantage. Hsematoxylon, kra- 
meria, kino, and the entire list of vegetable astringents containing 
tannin, have been from time to time recommended, but they possess 
no advantages over the active principle, and are, moreover, more likely 
to cause vomiting. 

Nitrate of silver in one large dose (1 grain in fresh pill) may be 
tried. 

Vinum ipecacuanhas has been extolled in 1 or 2 minim doses. It 
probably would be equally efficacious if applied externally to the skin 
of the abdomen in the same heroic proportions. 

Creasote, in the capsular form, has checked, for the writer, small 
hemorrhages in a very satisfactory manner. 

Where the hsematemesis is the result of congestion, caused by hepatic 
disease, a large dose of sulphate of magnesia or calomel, followed up 
with ice and revulsive measures, will be advisable. Watson's treat- 
ment was 5 grains of calomel at night, and 2 ounces of black draught 
in the morning. 

Hamamelis and chloride of ammonium, alone or combined with any 
of the previously mentioned styptics, may be tried in such cases. 

Stacey Wilson has drawn attention to the part played by varices of 
the oesophagus in producing hemorrhage in cirrhosis of the liver and 
other affections. He dwells upon the importance of securing rest to 
the gullet by prohibiting even the swallowing of ice, and he points out 
the uselessness of ergot, which probably drives the blood from the 
arterial system into the dilated varicose veins. Nitrite of amyl, he 
thinks, might act in the opposite way by drawing a large amount of 
arterial blood into the capillaries. 

Where the hemorrhage appears to be owing to a blood condition, as 
in purpura, turpentine, in mixture or capsules, along with ice and iron, 
affords the best hope of success. 

See the action of the various agents used in internal hemorrhage, 
mentioned under Hematuria, page 307. 

H^IMATIDROSIS. 

For the treatment of this rare and interesting condition of " bloody 
sweating" nearly every hemostatic has been recommended. The cases 
have occurred so infrequently, and tend to get well if let alone, so that 
little can be said about the value of remedies. 

As a rule, in vicarious cases, revulsive treatment by hot foot-baths, 
sinapisms, and saline purgatives should be tried. Many of the cases 
occur in healthy individuals, and should not be interfered with. 



H^EMATINURIA — HEMATOCELE. 303 

HJEMATINURIA, or HEMOGLOBINURIA. 

In the non-paroxysmal variety, where the urine remains during the 
illness constantly charged with the coloring matter of the blood, with- 
out the presence of any blood corpuscles, the treatment will embrace 
the remedies suitable to combat the causes of the disease. These are 
the ingestion of poisons, the most important of which are chlorate of 
potassium, carbonic, pyrogallic, sulphuric, hydrochloric, and carbolic 
acids, the poisons producing scarlet, typhoid, and other fevers, and 
the conditions of the blood following severe burns, fat-embolism, 
scurvy, etc. 

Paroxysmal 'klematinuria has a spontaneous tendency to com- 
plete recovery in all cases, and it is therefore doubtful if the many 
remedies said to be beneficial have the slightest influence over the 
condition. 

Quinine and arsenic appear to have some effect upon the urine, and 
the former remedy in 5 grain doses has been observed to stop the 
paroxysms in several cases, and in some instances they never returned 
afterward. Cinchona, in doses of 2 drachms of the compound tincture, 
has been used by Sir W. Gull with satisfactory results. 

Iron in large doses of the astringent preparations, or of the syrup of 
the iodide, or of the sulphate with sulphuric acid, has been said to be 
valuable. 

Tannic and gallic acids, iodide of potassium, alum, chloride of 
ammonium, mercurials, vapor baths, dry cupping over the loins, with 
copious hot drinks containing a little alcohol, and many other remedies 
suitable in hematuria, have been recommended. 

HEMATOCELE. 

The treatment of hematocele will be based upon the principles 
guiding the treatment after hemorrhage into internal parts. Thus, 
hematocele of the tunica vaginalis in the early stage will consist in 
putting the patient to rest in the horizontal position, lying upon his 
back, with a small light board placed across the upper part of the 
thighs. Upon this board or splint, as upon a shelf, the enlarged 
scrotal tumor is laid. Iced compresses, or ice tied up in gutta-percha 
tissue, is placed over it, or evaporating lotions upon lint are applied. 
Over all a cradle is placed, covered by the bedclothes, which should 
be light. 

A smart saline, as 1 ounce of Rochelle salt, in a tumblerful of aerated 
water, may be given. Leeching is rarely productive of good. When 
a hydrocele had previously existed before, the amount of effused blood 
will rarely be so great as to cause the tumor to solidify ; and even in 
cases where no effusion had previously existed, the tumor may remain 
fluid. Tapping with an ordinary trocar and canula is the best practice 
in such cases, but the surgeon should wait and satisfy himself that ab- 
sorption is not likely to take place before he resorts to tapping. The 
operation may be repeated at intervals, with a fair prospect of cure. 



304 HEMATOCELE. 

Where the tumor remains hard and tense, the best procedure is to 
make an incision through the skin, and by dividing the deeper layers 
carefully upon a director, there will be no danger of wounding the 
testicle, which is often placed in the front part of the tumor. The con- 
tents of the sac should be turned out through the large incision made 
into it, and after syringing, plugs of cotton wool soaked in weak cor- 
rosive sublimate solution may be inserted, and the sac left to granulate 
from the bottom. The same treatment should be adopted in fluid cysts 
when suppuration sets in, and it will often be advisable in such cases 
to insert a rubber drainage-tube after turning out the suppurating 
contents. 

In very chronic cases, where the sac walls are much thickened, after 
the free incision there may be difficulty in detaching the layers of par- 
tially organized clot. In such cases a portion of the thickened wall 
may be removed, or, as Gould recommends, the entire mass, including 
the testicle, may be excised. 

The same measures may be employed in dealing with hematoceles of 
the cord and of the testicle proper — i. e., rest, cold, tapping, or free 
incision, followed by antiseptic or iodine injections. 

Hematocele (pelvic) is a grave affection, and may cause death from 
shock, unless prompt measures be adopted. The writer once witnessed 
such a seizure take place in his presence, a patient who was perfectly 
well a few moments before being stricken down, as if shot by a rifle 
bullet. 

The patient should be rapidly undressed and placed on her back 
upon a hair mattress, with the pelvis slightly raised by a hard counter- 
pane folded neatly and placed under the buttocks. Collapse may be 
met with stimulants, such as ether, alcohol, or sal volatile. Opium is 
the only reliable hemostatic and restorative in such cases, and in the 
presence of great pain it may be given fearlessly. Small doses are 
useless ; 45 minins of laudanum by the mouth or anus, or J grain of 
morphine by hopodermic injection, should be administered as soon as 
possible, and the effect kept up by smaller doses, repeated every hour, 
according to the urgency or severity of the symptoms. In the inter- 
vals between the doses of opium brandy and ice may be freely given ; 
afterward brandy or whiskey in small quantity, diluted with iced milk, 
will constitute the best feeding during the early days following the 
seizure: As soon as possible alcohol should be stopped altogether. 
Local treatment should consist of cold compresses or crushed ice, 
folded in gutta-percha tissue or oiled silk, and laid over the lower 
parts of the abdomen. The vagina may be packed with ice in des- 
perate cases. At this stage some recommend brisk purging with calo- 
mel, croton oil, or strong salines. The writer has never had the courage 
to try these heroic remedies. Nor has he ventured to recommend tight 
abdominal bandaging. A large sinapism over the anterior surface of 
the abdomen may be employed as a revulsive measure where the col- 
lapse will not permit of iced compresses. 



HEMATOCELE. 305 

Cases with the gravest aspect generally recover if kept absolutely at 
rest and under the influence of opium, and meddling by making re- 
peated examinations and explorations is to be condemned. Many 
remedies may be tried with the view of arresting the internal hemor- 
rhage, of these ergot is the only one likely to prove of much use ; it 
may be given hypodermically, or by the mouth in full doses. Gallic 
or tannic acids, digitalis, turpentine, acetate of lead, iron, etc., may 
possibly only tend to divert the physician's mind from the administra- 
tion of opium, which after all is the remedy upon which the patient's 
salvation depends. 

In the face of a rapidly increasing internal hemorrhage, the opera- 
tion of opening the abdomen and securing the bleeding vessels may be 
weighed. If extra-uterine gestation or an ovarian varix is diagnosed 
this will be justified, but the hope of securing the vessels, from which 
an ordinary pelvic hematocele is fed, is indeed .visionary, and the vast 
majority of cases so treated would probably have their chances of 
recovery sadly minimized by such an attempt. 

The subsequent treatment will be that of peritonitis, pelvic cellulitis, 
or pelvic abscess. When the shock and collapse have passed away, the 
resulting peritoneal mischief will call for sedative measures constitu- 
tionally and locally. Opium should be still our mainstay, and until 
all danger of further hemorrhage has passed away cold compresses are 
to be preferred to hot poultices. These local anodynes are invaluable 
at a later stage when pelvic cellulitis is established. Iodide of potas- 
sium, or mild mercurials, may be given with the view of causing 
absorption. 

In the great majority of cases the effused blood will either become 
absorbed or an abscess will form which, if left alone, will find its way 
into the bladder, bowel, vagina, uterus, or through the skin. The 
practice of puncturing the tumor through the rectum or vagina is 
followed by some surgeons, there cannot be a doubt that such a routine 
practice is a serious mistake. When there is evidence that suppuration 
is already established, and the symptoms and signs lead one to believe 
that there is danger of the sac bursting into the peritoneal cavity, if a 
bulging soft point is felt in the vagina or rectum, to wait for spon- 
taneous rupture might be a fatal blunder. The aspirator should be 
discarded and a large trocar and canula, such as is used for puncturing 
the bladder, may be selected, and the canula should be driven well 
home after the withdrawal of the trocar. Should the contents of the 
cavity consist of coagula, as well as puriform fluid, the opening should 
be freely enlarged, and the sac well washed out with warmed solutions 
of corrosive sublimate, or Condy's fluid, injected from time to time 
through the ordinary enema apparatus, to which a large, soft catheter 
may be attached. Vaginal puncture is to be preferred to the anal, 
other things being equal. Tait has successfully operated upon several 
suppurating hematoceles by abdominal section. 



306 HEMATOMA — HJMATUEIA. 

HEMATOMA. 

Whether the extravasation of blood takes place under the skin over 
soft parts, under the skin, aponeurosis or fibrous membrane covering 
the cranial bones, or between the cartilage and the perichondrium, as 
often occurs in the ears of lunatics, the treatment is the same. The 
general principles which guide the surgeon in treatiug an hematocele 
maiutain here also — rest to the injured part, the application of cold 
lotions or iced compresses in the earlier stages, and afterward the influ- 
ence of local remedies calculated to promote absorption of effused pro- 
ducts. Poultices, aspiration, puncture, and incision -should not be 
resorted to unless there be clear evidence of suppuration having taken 
place, as the natural tendency in the great majority of cases is for 
resolution to occur spontaneously. Pressure by bandaging or strap- 
ping is a valuable method of assisting Nature in chronic or slowly 
progressing cases, and sometimes it may be found advisible to apply 
pressure over a spirit lotion covered in by a layer of oiled silk. The 
worst forms of caput succedaneum, and the rarer and more serious 
cephalhematomas, will almost invariably yield to expectant treatment. 

When suppuration occurs, aspiration is generally advised. It will 
be found much more satisfactory to make a. free incision into the centre 
of the swelling, press out the contents, and wash out the cavity with 
weak sublimate solution (1 : 5000), or swab it out with lint soaked in 
strong carbolic acid or iodized phenol, and leave in a drainage-tube 
under antiseptic dressings. 

Hematoma auris, if let alone and protected from injury, always 
yields to expectant treatment, and rarely requires incision, lotions, 
poultices, or pressure. 

HEMATURIA. 

It is useless to attempt to treat this condition until the source and 
cause of the hemorrhage are determined. Though this may in some 
cases be found difficult or impossible, nevertheless the first step should 
be to test the urine microscopically and chemically, investigate its 
color, reaction, and appearance immediately after micturition and 
upon standing, and to carefully examine the shape, diameter, and color 
of all clots by causing them to float in water. 

By examining the bladder with the electric lighted cystoscope, the 
exact site of the hemorrhage may be demonstrated with precision. 

A careful analysis of the history and symptoms in many cases will 
show whether the blood is urethral, vesical, or renal. 

Having made the diagnosis of the exact source of the hemorrhage, 
treatment may then be directed to the disease of which it is the symp- 
tom. If from the urethra the passage of as large a sound, catheter, or 
even rubber catheter, as the canal will admit, should be performed, and 
pressure made from without by bandage, or strapping, and ice. 

If from the bladder and the cause cannot be immediately removed 



HEMATURIA. 307 

(stone, ulcer, cancer, tumor, etc.), rest in the horizontal position, and 
the free use of ice or cold in the rectum, vagina, perineum, or over the 
pubes. Leiter's tubes may be applied to any of these regions with 
advantage. Should there be evidence that the hemorrhage, though 
vesical, is probably vicarious, as may be met with in cases of haemor- 
rhoids, or suppressed menstruation, the haernaturia should not be inter- 
fered with until the suppressed flux is suppressed. In such cases 
leeches may be applied, and smart purges administered. Notwith- 
standing rest and the free application of cold and ice, and the use of 
the internal haemostatics to be immediately mentioned if the hemor- 
rhage should continue, resort must be made to vesical injections. 

The most efficacious and the safest is iced water containing in solu- 
tion, alum 25 to 40 grains in each pint. The use of vesical injections 
will end in disappointment if the bladder be not first emptied with a 
large-eyed catheter of soft rubber connected with a clover or ordinary 
lithotrity suction apparatus before their introduction. This plan will 
be imperative if retention of urine from clots exist. 

Other haemostatics are injected : nitrate of silver (10 grains to 20 
ounces), hazeliue (1 to 2), solution of chloride or nitrate of iron (1 
drachm to 20 ounces). The writer has treated vesical hemorrhage in 
one case by the injection of castor oil in quantities of 2 to 5 ounces 
successfully. 

Harrison treats severe haernaturia from enlarged prostrate by empty- 
ing the bladder, and tying in a soft catheter, while pressure is made 
from without as in the case of post-partum hemorrhage. As long as 
the bladder is capable of exercising pressure there is little danger in 
these cases, but when from atony of its walls it is unable to contract 
completely the above means is the only way to stop what may become 
a fatal hemorrhage. 

Internal haemostatics may be employed at the same time as the injec- 
tions are being administered. 

When the hemorrhage is of renal origin, cold, by means of ice-bags 
or Lieter's tubes, applied to the loins may be tried. 

If the bleeding be the result of the ingestion of irritants like can- 
tharides or overdoses of turpentine, these drugs should be discontinued. 

Rest in the horizontal position is even more imperatively demanded 
than in the management of vesical hemorrhage. 

Where the hemorrhage is the result of a general renal congestion, 
dry cupping of the loins, hydragogue cathartics, strong sinapisms, or 
local wet packs or mustard packs may be tried. These are indicated 
in the treatment of haernaturia coming on in the early stages of acute 
Bright's disease where the application of cold is fraught with some 
risk. Such cases, however, seldom require treatment for the hemor- 
rhage. 

Internal haemostatic remedies may be employed where the quantity 
of blood coming from the vesical or renal region is such as to weaken 
the patient. Foremost amongst these remedies comes opium or mor- 



308 HEMOPHILIA. 

phine; it may be freely given where the kidneys are not diseased. Its 
use in Bright's disease is unsafe. 

Ergot may be given in large doses in all cases unless pregnancy 
should chance to be a complication. Hypodermic injections of ergo- 
tine (5 grains) may be injected deeply into the buttock, or loin. 

Some surgeons prefer sclerotic acid (1 grain). It is a substance of 
variable composition, and has no advantages over ergotine. 

Alum is a safe remedy in these cases, and may be pushed short of 
producing nausea. 

Gallic and tannic acids, rhatany, kino, catechu, matico, and cinchona 
may exert some influence. 

Acetate of lead (3 grains with J grain opium) every three hours, and 
large doses of the astringent iron preparations well diluted, are more 
certain in their effects and are valuable where purpura exists. 

Turpentine (5 minims) or creasote (2 minims) are still more likely 
to produce some effect upon the hemorrhage. 

Digitalis has occasionally given good results, and so has Indian 
hemp in an unexpected manner ; but both are very uncertain in their 
action. 

Hamamelis is lauded, but the writer never saw it do any good, and 
chimaphila seems to rest upon an equally undeserved reputation. 

The best results that the writer has witnessed in the treatment of 
renal hemorrhage he has obtained by jaborandi in doses of 30 to 45 
minims of the tincture (1 : 4). He was led to omploy it in hematuria 
after noticing its effects upon bloody urine when given in Bright's dis- 
ease, with the intention of producing sweating and elimination of urea. 
He has satisfied himself about its great value in most of the forms of 
renal hemorrhage from various causes. He hesitates to add another 
to the long list of substances used to check hemorrhage from the uri- 
nary surface, but the action of the entire list is uncertain and generally 
disappointing. 

HAEMOPHILIA. 

This being a congenital condition or a diathesis handed down by 
hereditary transmission, it cannot be expected that treatment by drugs 
will alter the condition of affairs to any appreciable extent. Every- 
thing that will raise the standard of health and maintain it at its great- 
est height will be needful. Good food, healthy clothing, abundance of 
ventilation, free open-air exercise and outdoor occupation, freedom from 
worry and pressure, a warm climate, and very regular habits may do 
much to modify the diathesis. 

Preventive treatment in the way of avoiding injuries, wounds, abra- 
sions, etc., must be a life-long object of care and solicitude. No sur- 
gical operation should be undertaken. Many deaths have followed 
the skilful extraction of teeth, and serious results have followed the 
most trivial scratchings. 

When bleeding has already occurred the treatment is most difficult, 



HAEMOPTYSIS. 309 

and very firm pressure and styptics may be promptly tried and may 
succeed in staving off danger. Absolute rest in bed is essential, and 
internal haemostatic remedies must be pushed to the extreme. Iron, 
lead, turpentine, ergot, alum, tannic and gallic acids, creasote, and 
digitalis may be tried. Iron is the best of these remedies, and Dr. 
Harkin has recorded good results from the combination of chlorate of 
potassium (5 grains) and tincture of iron (20 minims) four times a day 
in glycerin and water. Sometimes, after the failure and discontinuance 
of all remedies, the hemorrhage ceases when death is expected, and the 
patient makes a tardy recovery. 

Where the hemorrhage proceeds from the socket of a recently ex- 
tracted tooth the cavity should be packed with cotton wool soaked in 
the strongest solution of the chloride of iron, and a pad of the wool 
placed over the depression or gap in the dental arch and the jaws 
firmly bandaged together, or pressure may be continuously kept up by 
a plate held in position over the pad by attachments to the surrounding 
sound teeth until all trace of danger passes away. 

Wounds may be treated in a similar way by the strong chloride, 
soaked in lint, and bandaged firmly over the bleeding surface, which 
should, if possible, be kept elevated. 

Epistaxis should be treated by the pufF-ball (lycoperdon giganteum) 
and the other measures described under Epistaxis (page 254). 

The galvano-cautery may be tried in some instances, and transfusion 
should always be performed when everything else fails, and the patient 
shows signs of approaching death. It should not be thought of as long 
as there is a fair prospect of the hemorrhage ceasing, as the wounds 
produced by the operation become serious additional elements of danger. 
All authorities agree in forbidding marriage, and this should be strongly 
insisted upon with women bleeders, or female members of bleeder fami- 
lies, who may not themselves have shown evidence of the diathesis. 

Vaccination should be performed with great caution, and the punc- 
tures made as superficial as possible. Death has been known to result 
from the operation. 

For the joint affections common in bad cases of the diathesis, abso- 
lute rest and the application of cold evaporating lotions, followod by 
dry heat to the affected joints are indicated. Splints are necessary in 
very severe cases to insure thorough immobility. 

Extravasations of blood, bullae, or abscesses should never be inter- 
fered with surgically. Ligature of arteries going to the bleeding locality 
is useless. 

HEMOPTYSIS. 

The vast majority of the cases of the present affection will be found 
to arise during the progress of tubercular phthisis. In discussing the 
question of treatment, it is assumed that the blood is proceeding from 
small vessels cut across or ulcerated in the necrotic process associated 



310 HEMOPTYSIS. 

with the softening of tubercular nodules, or that the hemorrhage is 
coming from the bronchial capillaries. 

Rest is the first essential. The patient should be put to bed in bad 
attacks. He may be allowed to have his head and shoulders elevated 
with a bed-rest. All food should be liquid and cold. Milk is ample 
for the first few days. Alcoholic stimulants should be avoided in all 
cases, unless where there is great shock and prostration. Some authori- 
ties insist upon a very dry diet. 

Ice sacked in the mouth, or teaspoonfuls of iced water swallowed, 
afford a pleasant way of assuaging thirst, relieving cough, and check- 
ing hemorrhage. 

Speaking should be indulged in only when absolutely necessary. 

Counter-irritation by a poultice of mustard, made into a paste with 
cold water, should be placed upon the front of the chest. Hot poul- 
tices should be avoided, and warm applications tend to encourage the 
hemorrhage. If the quantity brought up is alarming, a large bladder 
of ice should be laid upon the front of the chest, or wetted towels, be- 
tween the folds of which pieces of ice or a mixture of crushed ice and 
salt is placed, may be laid on the thoracic wall. 

The good to be got from applications of ice to the chest occurs at 
once, or soon after the chilling of the skin. If the cold be continued 
for any length of time, more harm than good is certain to result, as 
has been demonstrated in Rossbach's experiments. Dry cupping has 
been found useful sometimes. 

The room should be kept cool and well ventilated, if possible with- 
out the patient being directly exposed to draughts. A large vessel 
filled with warm water should be placed under or about the bed, and 
into this turpentine should be poured in small quantities at frequent 
intervals, the object being to keep the air of the room saturated with 
turpentine vapor. The drug may be poured upon cloths suspended in 
the air, or it may be sprinkled upon sawdust or pine shavings in a safe 
corner of the room, away from the danger of ignition. This is the 
routine practice of the writer, and in mild cases little else need be done. 
The turpentine vapor seldom proves disagreeable, and it is an excellent 
antiseptic and haemostatic, and in some cases exercises considerable 
soothing influence over the cough, which so often complicates the 
treatment of the affection. 

Of internal remedies opium is valuable, unless where there is very 
profuse expectoration, associated with great weakness. It is in the 
early stages of phthisis, where hemorrhage may be abundant, that its 
use is best marked. Its contra-indications are the same in haemoptysis 
as in bronchitis, and in the latter stages of phthisis its effects should 
be carefully watched. A full hypodermic dose of morphine often acts 
well when not contra-indicated. 

The effects of the usual haemostatic remedies as mentioned (under 
Haematuria, Haematocele, etc.) are very uncertain and unsatisfactory. 

Ergotine should be our first hope in severe hemorrhage from the 



HAEMOPTYSIS. 311 

lungs, and no time should be lost in injecting deeply into the tissues 
one full dose, say 15 minims of the (1 : 3) hypodermic solution. Its 
effects may be kept up by small doses given by the mouth. It does 
not interfere with the action of other remedies of the same class, and, 
after the full hypodermic dose has been administered, the patient 
may, in desperate cases, begin with half-hourly doses of some other 
remedy. 

Alum may be given in doses of 5 grains every fifteen or thirty 
minutes ; it may be well dissolved in water, and 10 minims of dilute 
sulphuric acid can be given with each dose. 

It is idle to prescribe a remedy, to be given every four or six hours, 
to a patient pumping up blood every few minutes. He expects to be 
dead before the second dose falls due. The moral effect of having his 
remedy in such serious cases at hand, and to be used every fifteen or 
thirty minutes, helps to give him confidence, and tends to allay dread 
and excitement, which are highly injurious to him. It is wise, there- 
fore, to order one full dose of the remedy in a tablespoonful of mix- 
ture for example, and direct a teaspoonful of the same mixture to be 
given every quarter of an hour afterward, until the hemorrhage 
diminishes ; 30 grains of tannic or gallic acid, dissolved in 1 ounce of 
water, may be given when the haemoptysis begins, and one-eighth of 
this amount, in a teaspoonful of water, may be given every twenty 
minutes afterward. 

Acetate of lead may be given (with a little vinegar and morphine) 
in doses of 1 grain every hour, for eight or ten hours, and often appears 
to act fairly well. 

Turpentine in capsules, 20 minims, may be given at first, and 5 
minims every half-hour afterward for six doses. It may also be given 
in syrup and water, with a little ether. 

Digitalis is much recommended, but the writer believes that, in severe 
and urgent cases, it is much worse than useless. It takes many hours 
before a safe dose exerts its full action upou the heart and vessels, and 
to trust to it in emergencies, where every minute is of value, may be a 
fatal mistake. It is a remedy of great value in haemoptysis of small 
amount extending over many days. 

Where there is febrile action in strong subjects, aconite or veratrium 
viride may be given in small repeated doses. Tartar emetic and ipe- 
cacuanha have been given with somewhat similar intention to act as 
depressants. 

Nitrite of amyl has sometimes been found to act with great rapidity ; 
by dilating the vessels it may give great relief to the smaller arteries 
and veins, and, if at hand in severe cases, it should get a trial. 

Chloride of barium acts like digitalis, and has been recommended ; 
it is of doubtful value. 

Chloride of sodium is always at hand, and it sometimes shows some 
influence over haemoptysis ; 2 teaspoonfuls may be dissolved in a tum- 
blerful of cold water, and 1 tablespoonful of this solution may be given 



312 • HEMOPTYSIS. 

every five minutes. The chloride of ammonium is equally efficacious 
in similar doses. 

Cayenne pepper has been recommended in 5 to 10 grain doses by 
Cheron, who believes that it acts like ergot. The writer has no expe- 
rience of its action, and there is not much information available as yet. 

Hamamelis Virginica, or its distilled extract, hazeline, has been 
reported by very many to be a specific in haemoptysis and internal 
hemorrhages. There is still room for doubt about this action of the 
drug. Hazeline may be given in doses of I to 1 drachm, or more ; it 
can do no harm in any case. 

Astringent iron preparations are valuable, and may be given without 
fear if well diluted ; 30 minims of the tincture of the chloride, or 3 
grains of the sulphate or the acetate, given as Basham's mixture, are 
excellent haemostatics. 

Belladonna or atropine, the latter hypodermically, are solely relied 
upon by some physicians. 

Pyrogallic acid, though a dangerous poison, has been successfully 
used in haemoptysis and internal hemorrhages ; f grain every hour for 
eight or ten doses is a fair dosage. 

Antipyrine has lately been reported as very successful in several 
cases. 

Oxide of silver (1 grain every two hours), sulphate of copper (i 
grain every hour, or 5 grains as an emetic), bromide, nitrate, and 
chlorate of potassium ; the entire army of vegetable astringents, includ- 
ing matico and larch ; arnica, bryonia, hydrastis, copaiba, and canna- 
bis indica, have all been recommended and tried with varying successes 
scarcely warranting further trials. 

Shoemaker speaks highly of geranium maculatum. 

Revulsive measures must not be omitted from the list of remedial 
agents. A smart saline often acts in a surprising manner. The writer 
has witnessed, many years ago, in the practice of an old physician, 
startling results from bloodletting. In one case of pretty advanced 
phthisis, haemoptysis had been continuing for many hours and the 
patient was showing signs of sinking, when the physician, without any 
apparent hesitation, took out his lancet and struck a large orifice in 
the vein at the elbow, from which a gush of blood freely flowed. The 
haemoptysis instantly stopped, and the patient made a good temporary 
recovery. Though this was well nigh a quarter of a century ago, the 
writer has never had the courage to see it tried again. 

Sir A. Clarke has drawn attention to the occurrence of haemoptysis 
in elderly arthritic patients, and he recommends in such cases renewed 
counter-irritation, restricted use of liquid diet, sedative cough agents, 
alkalies, following calomel and saline purgatives, and iodide of potas- 
sium. 



HEMORRHAGE.- 313 

HEMORRHAGE. 

The treatment will depend upon the nature of the disease or injury 
which has led to the opening of the vessels from which the blood is 
poured. In internal hemorrhage the lines of practice will be found 
enumerated under the various headings of Hematocele, Epistaxis, 
Hematuria, Hemophilia, Hemoptysis, Hematemesis, Anemia, etc. 

In external hemorrhage the general treatment will be the same as 
for internal hemorrhage. 

Syncope, collapse, or shock may result where the bleeding has been 
extensive, and it may be the first duty of the surgeon to attend to this 
symptom. In this stage, bleeding has practically stopped, and nature 
is perhaps at the moment forming coagula to seal up the open vessel. 
If the surgeon could be sure that the collapse would certainly pass off 
by waiting, he should not use active measures to restore the circulation. 
The collapse or syncope may, however, be fatal if vigorous measures 
be not immediately undertaken to excite reaction. The skill, coolness, 
and sound judgment of the surgeon will be required to decide how far 
he may be justified in an attempt to allow nature to stop the open 
vessel or to establish reaction at once and tie the bleeding point him- 
self. If the bleeding point is beyond reach and the hemorrhage diffi- 
cult to control, to hasten reaction by pouring down the patient's throat 
large quantities of alcohol may in some cases be the worst possible 
thing to do. Stimulants must be freely given in desperate emergencies 
and when life is placed in great jeopardy by the collapse. The hypo- 
dermic injection of ether or sal volatile, or the rectal administration of 
brandy, may be required in some cases. The horizontal position must 
be rigidly enforced, and all operative procedures must be carried out 
in this position after extensive bleedings. The head should be kept 
low, and a free current of cold fresh air may be permitted to blow 
over the face. Strong ammonia or acetic acid to the nostrils, or a 
dash of cold water to the face, often restores consciousness in such 
cases. By elevating the lower extremities the blood may be caused to 
flow toward the empty heart, which may be thus stimulated to renew 
its pulsations, then pressure may be made upon the abdominal aorta 
or upon the femoral arteries, or a ligature or tourniquet may be ap- 
plied to the limbs, with the view of confining the blood to the brain 
and heart. As a last resort in desperate hemorrhages, an elastic 
bandage may be rapidly applied to one or both lower limbs, and an 
Esmarch's rubber cord tied round the thigh, near the groin. 

Transfusion may be performed. (See under Anemia, page 37.) 
Such procedures will seldom be required in private practice, but two 
years' experience as resident surgeon in a large hospital brings to 
mind many cases where patients were brought in a collapsed state, 
and where the promptest action was necessary to save life. A minute's 
delay sometimes may be fatal. The most profound collapse and 
syncope has been witnessed by the writer in hemorrhages following 
innocent-looking punctures of the venous plexes about the orifice of 

21 



314 HEMORRHAGE. 

the vagina, caused by fractured chamber-pots, etc. Such cases are 
not brought to hospital until almost too late. 

If pressure can be made upon the bleeding spot, there is no danger 
to be feared from active attempts to establish reaction. Once the 
bleeding point is secured, such attempts should be made without 
delay. 

In securing a bleeding vessel, certain cardinal principles should not 
be forgotten. If an artery be wounded, the wound in the skin and 
soft parts, if necessary, should be freely enlarged, and a ligature 
applied above and below the bleeding point in the vessel. Should 
the vessel be cut across, both its proximal and distal ends must be 
separately ligatured. 

Where the vessel is a small one, or the stream of blood limited in 
extent, firm pressure by a graduated compress and a skilfully applied 
bandage may be sufficient. In some cases this will be the best tem- 
porary treatment until reaction has been fully established, when a de- 
liberate dissection subsequently, after the application of an Esmarch's 
bandage will enable the surgeon to secure the wounded vessel, which 
could not be found at the time of the active hemorrhage. It may be 
even necessary in some cases to give up the attempt to find the injured 
artery, and to ligature the trunk higher up. The writer has success- 
fully done this in cases of cut-throat, where to waste time hunting for 
the divided branches would have led to fatal results. Acupressure, 
with a figure-of-8 ligature, may be the most rapid and complete 
measure in some cases. Torsion may be applied to the divided vessel, 
but it will be generally found that in these cases the ligature is more 
satisfactory. 

Veins may be dealt with in the same way as arteries, but often the 
elevation of the limb and moderate pressure will answer all purposes, 
as in the profuse hemorrhages sometimes following varicose ulcers of 
the leg. 

Styptics are not to be relied upon, though the writer has been able 
to control formidable hemorrhages, with almost magical rapidity, by 
thrusting a mass of the puff-ball (licoperdon giganteum), (see fifth 
edition of Materia Medica and Therapeutics, page 581) into the centre 
of a deep, spouting wound. The pengawar djambi, or paku-kidang, 
appears to act in a similar way (see same volume, page 596). 

Chloride, sulphate, or nitrate of iron, matico (in powder), ice, alum, 
tannic acid, Richardson's or Ruspini's styptic colloid, cauterization by 
actual, galvano- or thermo cautery, turpentine, hot Water (at a temper- 
ature of 120° or 125° F.), and many other astringents have been rec- 
ommended. In urgent cases, where bleeding is profuse, their trial will 
be a waste of precious time, though in trivial bleeding they will often 
meet all requirements. Their use prevents union by first intention. 

For capillary bleeding following extensive superficial wounds, oper- 
ations or flap amputations, the free exposure of the oozing surface to a 
stream of cold air or iced water, followed by moderate pressure, is 
generally all that is required. Such treatment is, however, generally 



HEMORRHAGE, POST-P ARTUM . 315 

useless until all clots have been removed and every trace of blood 
sponged from the weeping wound. 

The treatment of the wound after the successful closure of the bleed- 
ing vessels is to be conducted upon general surgical principles, and the 
constitutional treatment is to be based upon the lines laid down for the 
management of anaemia (page 38), modified by the complications 
present in each case. 

When active external hemorrhage is going on, it is scarcely neces- 
sary to say that internal hsemostatic remedies, such as may be valuable 
in haemoptysis, etc., are of very little use. The treatment of wounds 
and injuries in subjects of the hemorrhagic diathesis will be guided by 
the principles enumerated under haemophilia. 

HEMORRHAGE FROM THE BOWELS— See Melsena. 

HEMORRHAGE, Post-partum 

The treatment should be, in the first instance, preventive. Post-par- 
tum hemorrhage is a rare event when the cautious physician is present, 
and directs or carries out the necessary manipulations of the uterus 
during and after the completion of labor. 

After the complete expulsion of the child, the uterus should be 
grasped from above by the left hand of the accoucheur, and pressure 
steadily maintained after the removal or expulsion of the placenta. 
This pressure may, in the majority of instances, be very slight, just 
enough to enable the operator to feel confident that he can speedily 
apply considerable force at a second's notice should the uterus show 
signs of relaxing under his grasp. The thumb should be placed in 
front, and the fingers dipped down deeply into the relaxed abdomen, 
so as to seize and squeeze the uterus as firmly as if the operator had the 
organ in his hand outside the body. 

Most authorities now strongly urge that the placenta should not be 
expressed for at least half an hour after delivery, and many recommend 
that double this period should elapse before resorting to removal, Ahl- 
feld insisting that two or three hours should intervene between the birth 
of the child and the operation of expression. 

The habit of applying the pad and binder immediately after the 
removal of the placenta should be condemned. It has been the cause 
of many deaths from hemorrhage. With the binder in situ, as a rule, 
little can be known about the state of the uterine contractions. Under 
a well-adjusted bandage, it is quite possible for the uterus to relax and 
fill with blood, without giving any warning to the over- confident 
attendant. 

The young accoucheur will never regret the routine practice of keep- 
ing up a close watch upon the state of the uterine contractions for a 
considerable period after the expulsion of the placenta, before having 
the binder applied. It will be a good practice: 1. Never to apply the 
binder until after the child has been bathed and dressed ; 2. To give 



316 HEMORRHAGE, POST-PARTUM. 

one full dose (30 to 40 grains) of ergot immediately after or before the 
expression of the placenta ; 3. To count the pulse from time to time — a 
pulse of 100 often indicating or forecasting a smart hemorrhage, though 
the uterus may be felt quite hard under the fingers ; 4. The accoucheur 
should not give up pressure or kneading until the uterine contraction 
has become permanent ; 5. It is a good practice to put the child to the 
breast as soon after delivery as possible, in order to excite reflex uterine 
contractions. 

Where hemorrhage has already occurred it should be stopped by 
immediately grasping the uterus as just described, and by alternately 
kneeding and squeezing the relaxed organ all clots are expelled, and 
further hemorrhage for the moment prevented. If the placenta has 
not been previously expelled the kneading and strong compression ex- 
ercised by the fingers will probably cause its ejection. Should it still 
remain in the uterine cavity and the hemorrhage continue, its removal 
becomes imperative. This is done by the introduction of the hand into 
the vagina and uterus and the peeling off of the placenta from the 
uterine surface. 

It is well to remember that partial attachment of the placenta to the 
lower uterine segment is a common cause of hemorrhage, the upper por- 
tion in the superior segment of the uterus being firmly attached while 
the blood flows from the partially attached lower part of the placenta. 
In these cases operative interference may be demanded without delay. 

Should the hemorrhage continue after the extraction of the placenta 
and all the clots found in the uterus and vagina, notwithstanding the 
steady, firm kneading from above, the physician may again introduce 
his right hand into the relaxed uterine cavity, and pressing his clenched 
fist against his left hand applied above, he may freely squeeze, knead, 
or grind the uterine walls between, until firm contraction is established. 
In one apparently hopeless case the writer introduced a large sponge 
soaked in strong vinegar and withdrew his hand, keeping up strong 
pressure from above and squeezing both uterus and sponge until per- 
manent contraction was aroused. 

A less formidable procedure is to introduce the hand into the vagina 
and press the uterus firmly between it and the hand applied as before 
outside and above. By directing the tips of the fingers into the ante- 
rior or posterior vaginal cul-de-sac, the anterior and posterior uterine 
walls may alternately receive the chief portion of the pressure. 

Ice may be applied in either hand, or a large rounded lump may be 
inserted into the uterine cavity. Cold or iced water injections or irri- 
gations may be employed, and iced compresses may be applied to the 
genitals or abdomen. While keeping up compression for any length 
of time, it is a good plan for the accoucheur to have a large jug oi 
iced water into which he can immerse one hand while resting it after 
the muscular exertions entailed by the kneading process. The cold 
hand can then grasp the uterus, while the other is in turn dipped into 
he ice water. In this way, if no assistance is forthcoming, compression 



HEMORRHAGE, POST-PARTUM. 317 

may be kept up for a considerable period. The relaxed organ should 
not be intrusted into the hands of an ordinary nurse unless the phy- 
sician can place the utmost reliance upon her skill and steadiness. 

Hot water injections or irrigations of the interior of the uterus act 
as powerful local haemostatics and cause generally speedy and firm 
contraction. The temperature should be about 115° F. to 120° F. 

Vinegar or diluted acetic acid, as mentioned, may be injected or 
introduced upon a sponge into the uterine cavity. 

Alum, tannin, alcohol, acetate of lead, hamamelis, tincture of iodine, 
and many other substances have been recommended for local applica- 
tion ; but if the bleeding has resisted the previously mentioned meas- 
ures, the employment of these is only waste of precious time. 

As a last resort, the physician will proceed to inject into the uterine 
cavity a strong solution of chloride of iron. One part of the solid crys- 
talline ferric chloride in 10 parts of water is the usually accepted 
strength. The B. P. diluted solution or the U. S. P. tincture may be 
employed. Weaker solutions (half the above strength or less) may be 
used, and Spiegelberg strongly warns the practitioner against employ- 
ing the concentrated solutions which he affirms are exceedingly danger- 
ous. He uses a solution composed of a tablespoonful of the strong 
solution in 17 of water. The writer has injected the strong solution 
(1 of the solid in 10) without ever witnessing bad results, but his expe- 
rience is too limited to speak decidedly upon this point, though he 
would remark that as the injection of iron should never be undertaken 
except as a dernier ressort in cases of threatening collapse, it would be 
well not to waste the time spent upon trying a very weak solution, but 
in desperate cases inject the 1 : 10 solution. 

Weak injections might be profitably employed in the treatment of 
cases where persistent oozing results from a doughy, imperfect contrac- 
tion of the uterus. Some authorities condemn the injection of the 
iron solution, but recommend that the interior of the uterus should be 
swabbed out with it by means of cotton-wool soaked in the solution. 

The writer will certainly try the licoperdon giganteum in the next 
serious case of post-partum hemorrhage if he chances to have it at 
hand. 

Diihrssen plugs the entire cavity with a large strip of iodoform 
gauze, which he pushes up to the fundus, and fills the entire cavity 
and part of the vagina in a fan-like fashion. 

Eecent experience looks as if this iodoform gauze tampon is to be the 
most successful and least dangerous of all methods yet known for the 
treatment of post-partum hemorrhage. 

It acts in two ways : it excites the uterus to firm contraction, and 
it stops the bleeding by its direct pressure on the open vessels. The 
reports from numerous observers all over the world appear to establish 
the superiority of this method over the injection of iron plan. 

Koch has tried and suggested a new method which we hope will be 
seldom tried in this country. He inverts the uterus and puts a rubber 



318 HEMORRHOIDS. 

band round the neck of the inverted part, which he removes in six 
hours, after which the uterus is returned and ergot given. 

As regards internal or constitutional remedies, the whole list must 
be rejected save two tried members. Lead, tannin, digitalis, hydras- 
tis, capsicum, hamamelis, chloride of soda, alum, etc., are useless in 
the very cases where most needed. 

Ergot is the most valuable known drug in treating post-partum 
hemorrhages. It should be administered immediately after the bleed- 
ing has started, even if it had been previously administered during 
the labor or afterwards as a preventive of hemorrhage.. Full doses 
must be given, and there is no preparation equal in promptness to the 
freshly prepared infusion, save the hypodermic injection of ergotine 
(1 : 3). This latter should be always employed in urgent cases; 10 
to 15 minims may be deeply iujected into a muscle, or even into the 
uterine walls, in desperate cases, and may be repeated in from fifteen to 
twenty minutes ; 1 drachm of ergot, made into an infusion, may be 
administered by the rectum ; 4 or 6 drachms may be given in a severe 
case. This remedy should be always employed in conjunction with 
the local manipulations already described. 

Quinine is a valuable remedy, but must be given in very large doses 
in such cases; 15 to 20 grains in wafer paper may be administered. 
It is apt to cause vomiting, and its action is slow. 

Pressure upon the abdominal aorta, bandaging the lower extremities, 
and the various measures mentioned upon page 313, may be tried in 
desperate cases. Collapse must be met by stimulants, frictions, etc., as 
described upon page 133. 

After the firm and permanent contraction of the uterus is estab- 
lished, a well adjusted pad should be placed above the fundus of the 
uterus, and a tight abdominal bandage should be applied, and the 
patient closely watched until reaction has completely set in. Transfu- 
sion and other remedies for the acute anaemia following extensive 
bleedings, are enumerated in the previous article and under the head- 
ing anaemia, but the hypodermic or intravenous injections of weak 
saline solutions (chloride of sodium, 1 drachm ; water, 1 pint) give the 
best results and meet every requirement of the case. 

HEMORRHAGE FROM THE STOMACH— See under Hsemat- 
emesis. 

HEMORRHOIDS. 

There are but few affections in which there is greater scope for the 
intelligent and successful use of remedial, palliative, and preventive 
measures. The physician is generatly consulted during what is called 
by the patient, " an attack of piles," and it will commonly be found, 
as pointed out by Curling, that in these cases a varicose condition of 
the veins of the lower part of the rectum or anus has existed for years 
without causing any inconvenience. The " attack " has followed some 



HEMORRHOIDS. 319 

indiscretion in diet, excess in drinking, constipation, or other violation 
of some fundamental law of health. It may, therefore, be advisable 
to consider at this place 

Preventive treatment. — Sedentary habits should be given up for 
active, open-air exercise when possible, too much standing being as 
prejudicial as too much sitting. Clothing should be warm but not 
excessive, and special care should be exercised over the covering of 
the feet and lower extremities. Damp and cold to the feet being 
especially injurious. 

Constipation must be prevented by the various means enumerated 
under this heading upon page 140, and the evil influences of pressing 
or straining while sitting upon the ordinary ill-devised, modern 
water-closet seat, as previously mentioned, must be guarded against. 
Constant use of purgatives is a serious evil. One point should always 
be insisted upon by the attendant, it is of vital importance, i. e., that 
the prolapsed piles, or varicosed mucous membrane, should be gently 
pushed up after every evacuation. A great deal of the ordinary 
hemorrhoidal trouble is produced by the constriction of the external 
sphincter upon the prolapsed tumor, causing irritation, inflammation, 
thrombosis, and other mischief. This may be prevented or warded 
off for a long or indefinite time by attention to the above rule. 

Diet should be varied and regular, excess being avoided, and, as a 
rule, alcohol in every form is injurious except in very small quantities. 
As a rule, the diet best suited to the hemorrhoidal patient is the diet 
which keeps his bowels in the most desirable condition. A tablespoonful 
of pure oiive oil in the morning, or at the conclusion of dinner, some- 
times keeps the motions agreeably soft. Orange marmalade or stewed 
fruits are valuable, but figs in every form should be prohibited, as their 
minute, spherical seeds often lurk in the recesses between the lubules 
of the hemorrhoidal tumors, and seriously aggravate the tenesmus and 
discomfort. 

Absolute cleanliness and the use of the softest paper or sponge are 
daily essentials. 

Bladder, urethral, renal, pelvic, hepatic, intestinal, cardiac, pulmo- 
nary, and other causes of increased blood pressure in the inferior 
hemorrhoidal veins must be attended to. 

As a preventive and curative measure there is nothing more valuable 
than small injections of cold water. 5 to 10 ounces thrown up act as 
a tonic to the relaxed membrane and bloodvessels, relieves tenesmus 
and constipation, stays hemorrhage, and promptly puts an end to 
pruritis. 

The confection of pepper (Ward's paste), copaiba, confection of 
senna, sulphur, castor oil, tar, glycerin, turpentine, hamamelis, ergot, 
cubebs, pulv. glycyrrhize comp., infusion of beet root, rhus tox., and 
many other substances and combinations are believed to exert a bene- 
ficial action upon the diseased membrane when administered by the 



320 HEMORRHOIDS. 

mouth, but except for their laxative effects their action is doubtful or 
at the best uncertain, and reliance must be placed upon local remedies. 

The local treatment of hemorrhoids will vary with their exact situ- 
ation, and with the stage of the affection in which they may chance to 
fall under the care of the attendant. 

Inflamed piles, whether external or internal, are generally very 
painful, and often are accompanied by intense suffering when strangu- 
lation or constriction has been caused by the grasp of the sphincter. 
This agonizing pain is often best marked in cases where the pile is 
small and of comparatively recent formation. Sedatives, and not the 
kn fe, are indicated in such cases. Leeches to the margin of the anus, 
or near to the surface of the tumor, ice externally, or slipped inside the 
sphincter, or injections of iced water, may relieve pain and subdue con- 
gestion and throbbing. Fomentatians or hot poultices, smeared with 
belladonna or opium extracts, are often more soothing than cold, and 
what affords relief at one stage may be aggravating twelve or twenty- 
four hours afterward, and the physician must ring the changes between 
cold and heat, dryness and moisture. It will be necessary in such 
cases to effectually relieve the colon at once, and this is best done by 
copious warm water enemata, which may be repeated from day to day. 
Rest in bed in the horizontal position is an essential element in the 
treatment. Local anodynes are most unsatisfactory in their effects 
upon congested, inflamed, or painful piles. Remedies of this class very 
often aggravate the distress. Cocaine, pastes, ointments or lotions of 
belladonna, opium, morphine, chloral, chloroform, aconite, tobacco, 
hamamelis, hyoscyamus, carbolic acid, creosote, and iodoform, are 
often useless as pain relievers. 

Morphine in the form of suppository (J grain) will after some time 
give ease, but not until it affects the cerebrum ; in fact, it does not act 
as a local sedative in these cases. The pain is caused by the increased 
tension, and is not caused by the irritation or hyperesthesia of excori- 
ated nerve endings as in fissure or ulcer of anus. Hence, local deple- 
tion, hot fomentations, warm injections or poultices, or iced injections 
or compresses are to be relied upon. 

As a local rectal anodyne, when the tension has subsided, there is 
no remedy hitherto used equal to conium. The preparation introduced 
by the writer (see page 47) is the only good method of using the drug 
in the form of an ointment. It may be pushed up the anus or freely 
smeared over the tumor, or applied upon the poultices. Its use is not 
followed by the speedy relief which it causes in fissure or pruritus, 
nevertheless it will give better results than the ordinary remedies used 
to relieve the pain of inflamed piles. 

The ointment of galls, 10 parts, with opium, 1 part, is a favorite 
remedy in chronic cases, a little cocaine, or belladonna extract, may 
be combined with it, but where a local anodyne and astringent effect 
is needed, here again the combination of the conium ointment with 
sulphate of iron (10 to 20 grains to 1 ounce) is in every respect better. 



HEMORRHOIDS. 321 

Inflamed piles should never be cauterized, excised, or ligatured. If 
a thrombus form, a longitudinal incision should be made with the 
lancet and the clot turned out. If suppuration occurs a free incision 
with an abscess knife will give speedy relief. 

Sloughing piles are best treated by poultices. The inflammatory, 
or sloughing process, may end in the removal of the trouble, and may 
effect a permanent cure. 

In piles of long standing associated with periodical prolapse, slight 
hemorrhages, or mucous discharge, the habitual use of cold water injec- 
tions (5 to 10 ounces), absolute cleanliness, and frequent spongings 
with cold water, with the application of the conium and iron ointment 
after each motion, often suffice to effect a cure. 

In more obstinate cases, astringent injections, as tannic acid (20 
grains, water 3 ounces), sulphate of iron (10 grains, water 3 ounces), 
tincture of iron (1 drachm, water 3 ounces), hamamelis (4 drachms, 
water 3 ounces), alum (40 grains, water 3 ounces), hydrastis (tincture 
4 drachms, water 3 ounces, may be thrown up and retained as long as 
possible. Sometimes excellent results may be obtained by injecting i 
ounce of hazeline undiluted. 

Suppositories of the same substances may be used with advantage. 

Ointments are also useful, the best being sulphate of iron (30 grains 
to 1 ounce of lard). Dilute citrine ointment (1 : 3) is also a good 
application in chronic cases accompanied with mucous discharge ; it 
may also be used as a suppository. Lead acetate may be employed in 
the same way. These applications generally cause much pain and 
smarting. 

Nitric acid, or the strong solution of nitrate of mercury applied to 
internal prolapsing haemorrhoids, often gives satisfactory results. The 
speculum being introduced, and the surface of the pipe wiped dry, the 
strongest acid is freely applied by a piece of wood or a glass brush, the 
skin being very carefully guarded, and the cauterized surface smeared 
over with chalk and oil afterward. As a rule, there is not much pain 
if the patient keeps to bed for some hours, and excellent results often 
follow. 

Cauterizing the surface of the pile with a hot iron in a linear manner 
acts in the same way. Both remedies leave an eschar, which some- 
times is rapidly followed by shrivelling and disappearance of the 
enlarged vessels, and both are valuable methods of radical cure where 
the ordinary operations are contra-indicated, especially in cases where 
the tumor is small and sessile. 

The injection of strong carbolic acid into external or internal haemor- 
rhoids is not free from serious danger, and should not be performed. 
Edwards reports brilliant successes in thirty-eight cases by injecting 2 
to 5 minims of carbolic acid solution (1 : 10 of glycerin and water), 
with an ordinary hypodermic needle, into the centre of each pile, and 
returning it immediately within the sphincter. The results are most 
satisfactory, no trouble ever resulting, and the patient is rapidly cured, 



322 HEMORRHOIDS. 

without lying up a single day. Further reports will be awaited with 
interest, especially as other operators, who have given this method a 
trial, speak in a very different strain about it, reporting pain, inflam- 
mation, and failure as regards radical cure, and unless some new facts 
are broughs to light, the method will hardly stand the test of time. 

Unna's plan of treating piles by chrysarobin has been modified by 
Kosobudski, who uses an ointment of chrysarobin, 8 parts ; iodoform, 
3 parts; extract of belladonna, 6 parts; and vaseline, 150 parts. For 
internal piles he uses suppositories, which he claims cure in three or 
four days. The following is their composition : 



R . — Chrysarobini . . gr. j 

Iodoformi 
Ext. belladonna 
01. theobromse . 
Glvcerini .... 



gr- h 
gr. xxx. 

q. s.— M. 



The ordinary surgical methods of removing piles are by scissors, the 
knife, galvano-cautery, or ligature, or by clamping, cutting, and the 
actual cautery combined, or by crushing and excision combined. Ex- 
ternal piles may be removed by the use of scissors curved on the flat. 
As a rule, the hemorrhage is trivial. 

Cocaine (5 per cent, solution), carbolic lotion (1 : 30), or the ether 
spray will generally produce sufficient blunting of the cutaneous sensi- 
bility. 

McCarthy points out the danger of removing too much skin if the 
pile be situated close to the margin of the anus, as troublesome stric- 
ture of the orifice may result. This is unlikely. By catching up the 
folds of skin containing the pile with forceps, the scissors or knife 
should snip them off in lines radiating toward the anal aperture. The 
bleeding may be checked by the application of ice, or by the pressure 
of a pad of lint, held in position by a T-bandage. 

Internal piles may be removed by ligature. Chloroform may or 
may not be used. The operation is not necessarily a very painful one. 
The bowel should be well emptied by a large dose of castor oil the 
night before the operation, and a copious warm water injection should 
be given immediately before operating. If the patient possesses suffi- 
cient fortitude to undergo the operation without chloroform, he can 
readily bring the hemorrhoidal mass into view by straining after the 
action of the enema. Should chloroform or ether be administered, this 
can be readily accomplished by an assistant, who everts the mucous 
membrane. 

The patient lying upon his left side, with the legs well drawn up, an 
assistant separates the buttocks, and when the piles are well protruded, 
the surgeon seizes each with a toothed pile- forceps, and pulls very gently 
upon it, while he snips through the mucous membrane at its base with 
a pair of blunt-pointed scissors, leaving a groove round the insertion of 



HEMORRHOIDS. 323 

the tumor close to the intestinal surface. Some surgeons prefer to make 
this groove with a tenotomy knife. As the forceps are held by an 
assistant, who pulls gently upon the pile, the surgeon passes a stout 
waxed silk or hemp ligature around its base, taking care to include the 
entire mass, and allowing the ligature to sink into the groove as it is 
tied as tightly as possible. 

Each pile, when there are several, is treated in the same way, the 
ends of the ligature cut off, and the entire mass, with the short ends of 
the ligatures, should be returned within the sphincter. 

Where the pile is large and its base broad, after snipping through 
the mucous membrane at its base the surgeon should transfix it with 
a curved needle armed with a double ligature. After cutting its loop, 
each half should be tied separately. Some surgeons remove a portion 
of the strangulated pile before finally tightening the ligature. 

It is advisable to remove any external piles by scissors at the same 
time, taking care not to include them or any " intermediate " ones in 
the ligature while tying the internal ones. 

After the operation the patient should remain in bed and have a i 
grain morphine suppository, or a suppository of conium. Ice may be 
applied locally, though it is seldom required, and hot fomentations may 
be grateful. 

The bowels should be permitted to rest for three days at least, castor 
oil, cascara, or a large olive oil or warm water enema being required 
to start them after all pain, throbbing, hemorrhage, retention of urine, 
tenesmus, or other troubles are relieved. 

The ligatures should be allowed to come away, without any interfer- 
ence, as the bowels act. They often come away about the fifth or sixth 
day, but may be delayed until the twelfth. 

It is surprising how little pain follows the operation in many cases, 
and though occasionally the reverse is true, the writer has had diffi- 
culty in keeping the patient in bed for a sufficiently safe time. As a 
rule, ten or fourteen days should be insisted upon. Where there is 
much fetor, (a rare event), the rectum may be washed out daily with 
antiseptic lotions, or a suppository containing 5 grains of iodoform 
may be used. Hemorrhage may be met by ice, and injection of chloride 
of iron in weak solution, or the bleeding point may be touched with 
the strong solution or with the cautery after everting the mucous 
membrane and gently drawing down the piles by cautious traction 
made upon the ends of some of the ligatures. 

The operation by clamp and cautery is, upon the whole, preferable 
to the ligature. After a thorough evacuation of the bowel by a pur- 
gative or a large tepid water enema, or by both agents, the patient is 
placed upon his back and brought completely under the influence of 
chloroform or ether. The lithotomy position with the crutch is the 
best where assistants are not numerous, but some surgeons prefer the 
patient to lie upon his left side with the thighs well flexed and the 
nates separated by an assistant. By introducing both thumbs into the 



324 HEMOTHORAX. 

anus and making steady traction the sphincter is readily dilated ; the 
pile, seized with forceps, should be gently pulled down, and the clamp 
applied to its base. With a scalpel or bistoury the pile is excised and 
the actual, galvanic, or Paquelin's cautery applied to the stump, so as 
to burn it down almost to the level of the clamp, which is then re- 
moved, any bleeding point being again touched by the cautery, and 
the patient treated afterward as in the case of using the ligature. 

Allingham and others operate by using a powerful screw-clamp, 
which is applied to the base of the pile, and after applying strong 
pressure in a longitudinal direction for a couple of minutes, the pro- 
jecting portion of the tumor beyond the crusher is excised and the 
instrument removed. No hemorrhage whatever need occur, and speedy 
and comparatively painless recovery ensues. 

Whitehead's operation of excision of the entire pile area is not one 
to be recommended w T hen the ligature and clamp and cautery continue 
to give such satisfactory results. Mathews reported in 1888 that he 
had used the ligature in 1000 cases without a single recurrence of the 
disease and without a death. 

HEMOTHORAX. 

When this is caused by some blood condition, as in purpura, cancer, 
tubercle, etc., the treatment of the primary cause is of first importance. 
In such cases probably only a blood-stained serous fluid exists, and the 
management of the case will be best carried out upon the lines indicated 
for pleural effusion. 

Where active bleeding is occurring into the cavity of the pleura 
without any external wound, the case may be considered, in the major- 
ity of instances, as beyond the reach of art. Nevertheless, there are 
certain measures which may afford some hope. The patient. should be 
placed in bed, and have ice freely applied to the affected side; he 
should lie upon this side unless where this interferes with the repeated 
applications of the ice. Food should only be given in quantities just 
capable of maintaining life, and the utmost quiet and freedom from 
excitement must be maintained. 

Opium should be given in moderate doses, and of all the internal 
haemostatics there is only one worth trying in such cases, and this 
remedy is ergot, which may be given hypodermically in doses of 2 
grains of ergotine. Kapid purgation by a concentrated solution of 
magnesia sulphate, as recommended by Professor Hay in dropsy, may 
be tried. (See author's work on Materia Medica and Therapeutics, 
fifth edition, page 452.) The old heroic method of bleeding freely from 
the arm may, by rapidly making an impression upon the circulation, 
check internal hemorrhage. (See under Haemoptysis, page 312.) 

Where the blood has been already poured out in quantity sufficient 
to compress the lung and cause serious embarrassment to the breathing, 
a trocar and canula may be employed to draw off the fluid blood or 



HARE-LIP. 325 

the serum of coagulated blood. If a wound exist it may be enlarged, 
and a fair sized drainage-tube may be inserted into the pleural cavity. 

Should the hemorrhage be coming from a wounded intercostal or 
internal mammary artery, this must, if possible, be stopped by liga- 
turing both ends of the divided vessel after enlarging the wound. In 
order to accomplish this it may be necessary to remove a portion of 
the rib or its costal cartilage. 

Plugging of the wound may be performed in such a way as to ensure 
that the hemorrhage be not simply made to flow on internally after the 
aperture is closed externally. 

HARE-LIP. 

The first question to be decided in the treatment of this unsightly 
deformity is, "when to operate? " The answer will depend upon many 
considerations. Chief of these will be the ability of the infant to take 
nourishment. Should the cleft in the lip prevent the successful use of 
the mother's nipple the operation may be performed within the first 
week or ten days with advantage. 

As a rule, in this country the operation is deferred too long, the 
infant suffering in health from the difficulties of obtaining nourishment, 
so that when presented for operation it is not in a favorable condition. 
The first duty of the physician in all cases is to see to the nutrition, 
and if sucking is impossible or difficult, the infant should be fed from 
a spoon with the milk drawn from its mother's breasts until sufficiently 
strong to stand the shock of a cutting operation and its consequent 
hemorrhage. When there is no difficulty in sucking, the third month 
is a favorable time for remedying the deformity. Where there is pro- 
jection of the inter-maxillary bone, and cleft palate, the end of the sixth 
or eighth month will be early enough to think of operating. 

A towel being wound around the infant so as to fix its arms close to 
the body, chloroform is administered as the little patient lies upon his 
back on a table or upon the lap of a steady nurse, with his head rest- 
ing upon the knees of the surgeon. The lip must be thoroughly sepa- 
rated from its bony attachments by cutting and gently tearing through 
the reflected mucous membrane in the neighborhood of the cleft and 
beyond it, before any attempt is made at paring the edges of the cleft. 
After the soft parts are found to glide freely over the alveoli a fine, 
sharp, scalpel is used to pare off and completely detach the edge of one 
side of the cleft until the red margin of the lip is reached, when the 
incision is prolonged clean through the blunt angle and for a short 
distance along the free margin of the lip by turning the cutting edge 
of the blade outward. The remaining edge of the cleft is similarly 
pared until the lower angle of the cleft is reached, when the knife is 
again turned outward to continue the incision along the red margin of 
the lip without detaching the dissected paring, which is then stitched 
to the opposite blunt angle so as to fill in the notch which would other- 
wise be left in the free margin of the lip. 



326 HAY FEVER. 

One or two fine hair-lip pins are inserted, about one-third of an inch 
from the margins of the wound, through all the tissues down to the 
mucous membrane, the lower pin being adjusted first. By means of a 
twisted suture the margins of the cleft are brought together, fine horse- 
hair or silver sutures being inserted at intervals between the pins and 
along the lower margin of the cleft, so that complete and accurate 
adjustment of the edges of the wound is obtained in all its extent with- 
out any pouting or puckering being visible on the superficial or mucous 
aspects of the lip. To secure this latter desideratum, a few fine sutures 
should be put in upon the deep or mucous surface of the lip. With 
cutting pliers the pins are cut short, and a few pieces of waterproof 
adhesive strapping laid on across the lip and cheeks from ear to ear, so 
as to remove all tension upon the lips of the wound. A Hainsby's 
truss answers the same purpose. The pins may be removed inside 
of forty-eight hours, and the sutures gradually cut through one by one 
from the third or fourth day as union progresses. Much of the success 
of the operation depends upon the careful nursing of the first few days, 
and an experienced nurse is of the greatest value. The child should 
be spoon-fed for five or six days until union is complete. 

Bird's method of operating by the rectangular flap ensures the mini- 
mum of deformity, especially in those cases where there is a marked 
want of symmetrical form between the sides of the cleft. 

In double hare-lip the margins of the clefts are to be treated in the 
same way, and, if there be no bone displacement, the operation on both 
sides being carried out at the one sitting the case presents no difficulty. 

Where the inter-maxillary bones project, they must, if possible, be 
preserved by twisting them into their proper place or by severing par- 
tially their posterior attachments and forcing them back with strong 
forceps into the gap in the anterior part of the hard palate. Their 
destruction means the loss of the central and perhaps of the lateral 
incisors. After repeated failures in obtaining union, paring of the 
edges of the cleft may again and again be tried with some prospects 
of succcess at a later age. 

HAY FEVER. 

Volumes have been written on the pathology and treatment of this 
very troublesome affection, and the greatest differences of opinion 
still exist upon the best means of dealing with it. Several distinct 
disorders have been described as " hay fever " by different writers, 
and this has led to much confusion and disappointment in treating 
them. 

The great majority of cases, as clearly pointed out by Bronner, may 
be divided into two well-marked classes, i. e., those in which the mucous 
lining of the nasal passages, perfectly normal at all other times, swells, 
becomes congested, secretes freely, and is associated with sneezing and 
coryza. 

the second group of cases includes those where the signs of chronic 



HAY FEVER. 327 

hypertrophic rhinitis are always present, as evidenced by a thickening 
of the mucous membrane covering the lower and sometimes the upper 
turbinated bones, the septum, and nasal floor. 

This latter group is the more common, and, when the hay season 
comes on, furnishes a large number of the cases of so-called hay 
asthma or hay fever. The first class of cases, though amenable, to a 
certain extent, to purely local treatment, are neurotic in their origin 
and require constitutional remedies. The second class must be boldly 
met by local agents, and it is in dealing with them that the most satis- 
factory and lasting results have been obtained. There is litte use in 
the application of sedative or caustic solutions for the removal of the 
chronic rhinitis ; by far the best measure is the galvano-cautery and 
cocaine. 

The object is to so cauterize the erectile tissue as to form an adherent 
cicatrix which will permanently bind down the mucosa to the perios- 
teum, and, at the same time, ensure the complete destruction of the 
hypersensitive areas existing in the nasal membrane. By a 15 per 
cent, cocaine solution the thickened mucous lining is rendered insensi- 
ble, after which, with a fine blade or platinum point, a deep groove is 
burned with the galvano-cautery along the entire length of the inferior 
turbinated bone. 

There is a very fair prospect that the removal of the hypertrophic 
rhinitis will prevent, or very materially modify, the paroxysmal 
sneezing and coryza produced by the inhalation of pollen and dust. 

The treatment of those cases of true or neurotic hay fever in which 
no structural alteration is apparent in the nasal membrane, except at 
the time of the attack, is much less satisfactory. In such cases reme- 
dial measures must be directed, (1) to the neurotic state, (2) to the local 
hypersesthetic condition, and (3) to the prevention of the access of the 
irritant. 

The first indication is best carried out by the use of every means, 
whereby the highest standard of health can be maintained in the 
intervals between the attacks. Tonics, like arsenic, zinc sulphate or 
valerianate, iron, bromides, quinine, strychnine, iodides, shower-baths 
or sea bathing, are certainly worth trial during the months preceding 
June ; while the attack is on they may be worse than useless. The 
indication for each remedy will be found by studying the peculiarities 
of each case. 

Coupled with such preliminary treatment directions should be given 
to the patient whereby he may attempt to avoid the irritating cause of 
the seizures. Any locality where the pollen of grasses and other 
plants exists in abundance should, as far as possible, be avoided. City 
in-door life, a sea voyage, or residence in a high altitude, or a sojourn 
at a seaside spot, destitute of much vegetation, may enable the victim 
of hay fever to stave off the attacks. Respirators, goggles, veils, and 
plugs of cotton wool in the nostrils may in some cases mitigate the 
amount of coryza and sneezing by preventing the admission of the 



328 HAY FEVER. 

pollen grains, but, as a rule, their use causes acute discomfort, and, as 
preventive remedies, they are generally unsuccessful. 

Treatment directed to allaying the local irritation is of more 
importance than constitutional or tonic remedies. 

Antipyrine in full doses (15 grains) in some cases possesses the power 
of cutting short the attack. Should it fail after a few trials it may 
safely be abandoned. 

Morphine, aconite, pilocarpine, lobelia, muscarine, caffeine, salicylic 
acid, veratrum viride, grindelia, atropine, hazeline, bromides in full 
doses, quebracho, and many other powerful drugs have been adminis- 
tered with very indifferent successes, and with the exception of the 
occasional usefulness of antipyrine or^antifebrin, remedies given by the 
mouth, are generally most unsatisfactory, and the physician has to 
place his reliance upon local treatment. 

Of all the innumerable local remedies there is none to equal in 
rapidity and certainty the free use of the galvano-cautery. After local 
anaesthesia the sensitive areas on the nasal membrane should be 
destroyed, and an adherent cicatrix produced over the surface of the 
inferior turbinated bone, with a view of preventing erection of the 
mucous membrane, as already described upon page 327. In propor- 
tion to the thoroughness with which the operation is carried out will 
the success be, and sometimes the cauterization must be repeated 
several times. 

Next in value and less formidable, at first sight, is a method of 
treatment introduced by Sir Andrew Clarke. In the writer's hands 
it has given much satisfaction, one case yielding completely to its use. 
The interior of the nose and the pharynx (through the nostrils) are 
freely swabbed out with the following solution: 

Jjt. — Glycerini acid, carbolici (1:4) . . . ^ij. 

Quininfe hydrochlor gij. 

Hydrarg. bichlor gr. j.— M. 

S. — To be applied to the inside of the nostrils. 

Its application is followed by paiu and smarting and considerable 
aggravation of the local irritation. This, however, speedily subsides. 

W. Williams reports highly of a nasal spray, after failure of most 
of the above, consisting of a 1 in 1000 solution of the iodide of 
mercury. 

Cocaine has been extensively tried as a local anaesthetic in this 
affection, and notwithstanding the warm praises of Ringer and Murrell, 
it has not gained in favor. In selected cases where the paroyxsms are 
severe and short, its application is followed by a relief which justifies 
its use, but, as a rule, its effects are too transient to make an impression 
upon the disease. 

A 10 per cent, solution almost immediately reduces simple erection 
of the mucosa and relieves nasal obstruction, but, as pointed out by 



HAY FEVER. 329 

Hall, the secondary effect of the drug is to cause dilatation of the 
vessels which finally leads to increase in the thickness of the membrane 
and aggravation of the disease. 

Tabloids, containing \- grain, may be gently pushed up into the 
nostril as far as they can be carried by the tip of the little finger, and, 
as a rule, speedy temporary relief may be thus easily purchased. 

A spray may be employed when time is not an important factor, 
but the tabloids can be carried about by the patient and used at a 
moment's notice. Antipyrine solution (15 grains to 1 ounce water) 
may be used as a spray, and is not open to the serious objections that 
maintain against the habitual use of cocaine. Its effects are not, 
however, so prompt or pronounced. 

H. C. Wood recommends bougies of cocao butter containing each 
1 grain cocaine and t -J-q- grain atropine, thrust in between the septum 
and the swollen turbinated bones while the patient is lying down. 

Menthol rubbed over the sensitive areas is also in some cases 
efficacious in checking or modifying the attack. Hill uses a 10 to 20 
per cent, solution in oil, brushed or sprayed over the sensitive 
regions. 

Xitrate of silver (5 to 15 grains to 1 ounce.) may be used with a 
brush. 

Terebene, creasote, pinol, bromine, iodine, camphor, carbolic acid, 
or oil of peppermint or eucalyptus, mixed with hot water and used as 
an inhalation, have been often productive of benefit in allaying irrita- 
tion, relieving sneezing, and checking coryza. 

Chloroform has been resorted to with advantage — the vapor of a few 
drops inhaled from the handkerchief or the palm of the hand. 

Strong acetic acid or ammonia inhaled from a bottle is a harmless 
and convenient remedy, and is sometimes beneficial ; and strong lini- 
ment of iodine (1 : 10) may be used with advantage in the same 
manner. 

The usual asthma remedies, as Girdwood's and Himrod's powders 
(see Asthma, page 58), burning nitre papers or cigarettes, or smoking 
stramonium, datura tatula, lobelia, or tobacco may be tried. 

The nasal douche is of much value in some cases, and by its means 
corrosive sublimate (1 grain in 5 ounces), boroglyceride (20 grains to 
1 ounce), quinine (1 grain to 1 ounce), iodide of potassium (4 grains 
to 1 ounce), iodine (J grain to 5 ounces), aconite (2 minims of the 
tincture to 1 ounce), hazeline (1 drachm to 2 ounces), sulphurous 
acid (2 drachms to 5 ounces), carbolic acid (1 drachm to 10 ounces), 
tannin (3 grains to 1 ounce) may be applied to the nasal membrane 
and back of the pharynx. 

The various snuffs consisting of bismuth, sugar, morphine, gum, etc., 
are w T orse than useless. 

22 



330 HEADACHE. 

HEADACHE. 

As headache is but a symptom of a large number of widely different 
affections, its treatment cannot in a work like the present be discussed 
satisfactorily under this heading. Where headache is a prominent 
symptom of any disorder its management will be fully referred to 
under the name of the disorder. (See Meningitis, Megrim, Typhus and 
Typhoid Fevers, Amenorrhoea, Bright's Disease, etc.) 

The only rational treatment of headache must consist in an attempt 
to remove its cause when this is possible, and the most common cause 
which the physician meets with in practice is some altered or poisonous 
condition of the blood manifesting itself by its toxic influence upon 
the cerebral centres. The general rule in such cases should be to so 
act upon the eliminatory organs as to cause the excretion of the offend- 
ing material from the system. The marked success following the 
purging, sweating, and diaphoretic remedies given to relieve the intense 
cephalalgia in uraemia is a striking proof of this ; so also is the magi- 
cal effect of active open-air exercise in giving relief to the headache 
caused by breathing impure air or an atmosphere impregnated with 
carbonic or other gases. The headaches of fevers and inflammatory 
conditions, though probably depending upon a similar cause, is not so 
dealt with, as the abnormal heat production and manufacture of the 
toxic agent progresses in spite of treatment. Nevertheless, consider- 
able relief may be obtained in such cases by antipyretics and by 
smart counter-irritation to the back of the neck and occiput. 

It is worthy of note how frequently a sinapism applied to this 
region relieves many different varieties of severe headache depending 
obviously upon different causes. 

Congestive headache is speedily relieved by smart purging, and 
counter- irritation applied to the lower extremities, and in severe cases 
leeching, cold affusion, ice, and bromides. 

Anaemic headache, upon the other hand, is amenable to iron, qui- 
nine, stimulants, and concentrated food, remedies which aggravate the 
foregoing condition. This class of cases is sometimes greatly relieved 
by small doses of nitro-glycerin or amyl nitrite. 

Headache depending upon occular troubles and astigmatism yields 
speedily to measures which correct these causes; and as this form of 
cephalagia is much more common than is generally imagined, the care- 
ful examination of the eyes in obscure cases should not be overlooked. 
The writer has seen some cases of severe and chronic cephalalgia yield 
almost immediately to skilfully selected spectacles. 

The reflex headache, depending upon stomach troubles and acute 
dyspepsia, subsides rapidly after evacuation of the gastric contents. 
Hence the great value of emetics in such cases. The mineral acids, 
bicarbonates of soda and potash, and nux vomica often relieve cases 
belonging to this group. Oil of eucalyptus, in doses of 5 minims, 
often relieves various forms of headache. 



HEAD INJUKIES. 331 

Uterine and menstrual derangements, as a cause of headache, are 
well recognized, and, as a rule, the head pain rapidly subsides upon 
the removal of the cause. 

Gout or uric acid diathesis is sometimes associated with severe head- 
ache, and, notwithstanding the high praise given to full doses of sali- 
cylate of soda, the writer has found it often fail utterly. The white 
mixture, in full cathartic doses, does better than anodynes. 

Under megrim will be fully enumerated the host of remedies used 
to relieve nervous and sick headaches, and though the mysterious and 
striking powers of antipyrine and antifebrin are best demonstrated in 
severe migraine, nevertheless it must be remarked that in many cases 
not migrainous these remedies relieve pain in a remarkable manner, 
and as routine agents for the relief of headache they are much more 
valuable than bromides and caffeine. 

Electricity has been tried with varying success in several varieties 
of headache. The writer has obtained good results from a weak con- 
tinuous current of four Leclanche cells where other measures failed. 
Large doses of iodide of potassium have the same peculiar property of 
relieving deep-seated, obstinate cephalalgia, and in the headache 
depending upon cerebral tumors, it should always be steadily adminis- 
tered, and the dose may be increased until 30 grains are reached. 
Alternating with the doses of this drug, full quantities of antipyrine 
may be given, in conjunction with a series of small blisters upon the 
scalp, and counter-irritation to the nape of the neck. 

The headache caused by inflammation of the frontal sinus is treated 
by Seiss w 7 ith pledgets of cotton w T ool soaked in a 5 per cent, solution of 
cocaine, after which any mild antiseptic spray is used, and when all 
discharge is washed away, he insufflates the nostrils with a powder con- 
sisting of 6 grains of morphine, 1 grain of atropine, 2J drachms of 
bismuth, and H drachms of acacia. 

HEAD INJURIES. 

The uncertainty of diagnosis renders the treatment of these affec- 
tions more than ordinarily difficult and embarrassing. Only a faint 
and imperfect outline of their management falls under the scope of the 
present volume. Considering that the most serious consequences may 
ultimately follow injuries which leave no visible external mark behind 
them, the surgeon will be wise who treats all head injuries as serious 
when first coming under his notice. 

The key to the diagnosis and treatment of these accidents is to be 
found in a careful examination of the mechanical forces at work in the 
production of the injury. Only in this way can a fair estimate be 
made of the amount of damage sustained by the cerebral tissue and 
bloodvessels, simple w T ounds of the scalp and fractures of the cranial 
bones possessing little importance, unless when associated with internal 
laceration or contusion. 

Concussion symptoms, if present, are to be treated by absolute rest 



332 HEAD INJURIES. 

until reaction sets in (see Concussion, page 134, and Collapse, page 133), 
warmth to the surface by hot-water bottles and warm flannels, and, in 
cases of severe concussion and collapse, rectal injections of warm milk. 
Counter-irritation to the extremities m a mild form may be tried, but 
alcoholic or other stimulants must be avoided, or only given in most 
exceptional instances. 

The great difficulty in dealing with these cases is to avoid falling into 
the error of doing too much. Where reaction is slow of appearing, 
there is probably some serious damage to the brain, and if the attendant 
cannot restrain himself and assume a position of masterly inactivity, 
his interference, prompted by a feeling that he must do something, will 
probably result in hastening a violent reaction, which may end in further 
hemorrhage or encephalitis. 

When the rallying stage has ended in reaction, rest and absolute 
quiet should be maintained. One smart purge — 5 grains of calomel or 
half a minim of croton oil— may be given. Where these are contra- 
indicated, a copious warm water enema may be substituted. The 
patient should lie in a darkened room upon, his back, with the head 
elevated and the hair removed, with ice or Leiter's tubes applied to 
the scalp in severe cases. 

Leeching, wet cupping, or venesection may be demanded in plethoric 
subjects with much mental excitement. Alcohol, opium, and animal 
food are to be forbidden, the diet consisting entirely of milk, diluent 
drinks, and harmless slops. The use of even beef-tea is sometimes fol- 
lowed by an increase of headache and a rise of temperature, and a 
pure vegetarian diet should be insisted upon for a considerable time 
after the symptoms have subsided. As the symptoms of reaction and 
the excitement subside, the maintenance of rest and quiet for ten to 
twenty days generally leaves the patient well, unless serious cerebral 
damage has occurred. 

In those cases where the original injury was caused by a bad fall, or 
by the blow of a large, heavy object, the general contusion of the brain 
which results may end in fatal collapse. 

It is not often that surgical measures are indicated in this class of 
cases, as the diffused injury to the brain, if not relieved by the above 
treatment, will not be at all likely to yield to operative interference. 
Should, however, the symptoms of encephalitis follow reaction and end 
in signs of cerebral abscess, and if the pus can be localized, trephining 
may be determined upon with some prospect of success. Such a pro- 
cedure is only to be undertaken in this class of cases after the gravest 
deliberation and analysis of symptoms. Local brain symptoms, in 
cases of general shaking or severe brain contusion, may be present 
merely as part of the general brain injury, which of itself will be suf- 
ficient to produce a fatal issue, even after the local trouble has been 
successfully dealt with. 

Bryant advises local interference only in local injuries, but recent 
results prove that the inflammatory effusion and abscess following gen- 



HEART, DILATATION OF 333 

eral cerebral contusion or laceration may be dealt with successfully by 
trephining. 

In those cases where the injury is localized, as in blows, and wounds 
produced by sharp instruments, or by any force acting upon a circum- 
scribed area of the skull, and causing fracture of the cranial bones, with 
or without depression and associated with local brain symptoms, the 
line of action is clear. Depressed bone should be elevated without 
delay. Blood effused underneath the site of injury and causing com- 
pression symptoms should be removed by trephining. 

Authorities differ regarding the wisdom of elevating depressed bone 
when there are no symptoms of compression. Recent experience points 
strongly to the advisability of not waiting for signs of compression or 
irritation. Considering the cases in which the physician finds symptoms 
of local convulsions following long after circumscribed cranial injuries, 
there should be no hesitation in following Macewen's advice. 

He states that when there is marked depression of the skull, involving 
both tables, it ought to be elevated without waiting for the development 
of symptoms of compression or of irritation, provided the surgeon has 
the means of preserving the wound in an aseptic condition. 

The use of the trephine in fractures of the base of the skull has not 
been much practised. Warren has given some instructive cases where 
trephining was successfully performed with the view of affording drain- 
age, the cribriform plate being drilled for this purpose. He recom 
mends trephining above the external auditory meatus in fractures of 
the temporal and sphenoid bones and those involving the anterior fossa, 
and he selects the occiput below the superior curved line, with the view 
of draining the posterior fossa. 

In a fracture involving the vault of the pharynx, he recommends 
trephining a little anterior to the auriculo bregmatic line, and the in- 
sertion of a drain of antiseptic gauze along the floor of the skull in the 
route of the fissured bone. 

In fractures of the base, it is of vital importance that the avenues 
through which septic matters may be introduced should be guarded, 
thus irrigation and insufflation of the nostrils, ears, pharynx, and Eus- 
tachian tubes should be carefully attended to by means of sprays of 
weak corrosive sublimate (1 : 1000) or of carbolic acid (1 : 100), and 
the packing of the ears and nose with iodoform or other antiseptic 
gauze. 

HEARTBURN— See Dyspepsia. 
HEART, Dilatation of. 

This may be a sequel to valvular lesions, and indeed is often the con- 
dition which tempts the subject of valvular disease to seek the advice 
of the physician. Under these conditions the treatment for failing 
compensation — i. e., cardiac tonics and rest, with attention to the 



334 HEART, FUNCTIONAL AFFECTIONS OF. 

bowels, kidneys, skin and liver — will meet all the requirements of the 
case. 

Similar treatment will maintain in those cases where the dilatation 
has been brought on by severe prolonged muscular exercise or heavy 
mental or emotional strain. Broadbent points out the necessity of re- 
lieving the ventricles of work, and giving them strength, while at the 
same time measures are employed with a view of depleting the venous 
engorgement. 

Rest and cardiac tonics fulfil the first indications, while mercurial 
and saline purgatives accomplish the second. Often cardiac. tonics fail 
in giving relief until the balance of the circulation is restored by drain- 
ing the portal system. The after-treatment will then practically resolve 
itself into the judicious exhibition of the various agents indicated in 
cases of advanced valvular disease associated with failing compensa- 
tion. The hypodermic injection of strychnine is invaluable at the begin- 
ning of the treatment. 

HEART, Functional Affections of. 

Where an organic cause for cardiac disturbance exists, embarrassed 
respiration, palpitation, pain, and irregularity of action may demand 
prompt treatment. One or all of these symptoms may be present, and 
the treatment should be directed to the relief of the paroxysmal attack 
in the first instance, and secondly, to its prevention during the inter- 
vals, and thirdly, to the continuous treatment of the case in those sub- 
jects where the symptoms are more or less constantly present. 

Under Goitre Exophthalmic, and under Angina Pectoris, the man- 
agement of these affections are described. 

Attacks of severe functional disorder should, if possible, be referred 
to their source before effective treatment can be directed against them. 
Thus, an overloaded stomach, or an attack of acute dyspepsia, may 
produce alarming cardiac symptoms, which may be best treated by 
prompt evacuation of the gastric c mtents. Any rapid accumulation 
of gas or fluid in the abdomen may cause such displacement of the dia- 
phragm as may lead to serious cardiac embarrassment, and when pos- 
sible the cause should be remedied at once. 

In attacks depending upon intrinsic causes, as altered innervation, 
etc., the best remedies will be stimulants, like ammonia, ether, brandy, 
and in hysterical females, asafoetida, valerian, musk, or sumbul, while 
the paroxysm is severe. 

Ice or cold applied to the cardiac region, sometimes gives relief, but 
where there is marked irregularity or intermittent action this is not a 
safe practice. The same remarks apply to galvanism and faradization 
of the vagus of the neck. 

A little ether, inhaled from a sponge or inhaler, is safer than chloro- 
form, and where there is increased arterial tension nothing gives such 
marked relief as a nitrite of amyl capsule or a nitro-glycerin tabloid. 



AFFECTIONS OF. 335 

Ammonia or strong acetic acid, or even strong snuff to the nostrils, 
sometimes gives speedy relief. 

Aconite is recommended, but it may do mischief unless there be 
marked hypertrophy present. Veratrum viride is open to the same 
objection. 

Digitalis is generally useless when given to relieve a paroxysm, and 
bromide of potassium is also quite too slow in its action. Chloral hy- 
drate is of much value, but should not be given if there be a reasonable 
suspicion of organic disease, and if administered at all it should be given 
with a moderate dose of whiskey. 

Warm carminatives, like the strong tincture of ginger, may be added 
to the ammonia or ether with advantage, and a cordial like the follow- 
ing will generally prove speedy and efficacious : 



R. — Spt. ammon. aromat. 
JEther. fort. 
Tinct. zingiberis 
01. mentkse pip. 
Spt. camphorse 
Tinct. card. comp. . 
S. — Take a small teaspoonful in a w 



• 3ij- 
. 3 v. 

• 3h 

• 3iij- 
ad 3 iij. — M. 

neglassful of water every fifteen min- 



utes while the palpitation and difficulty of breathing are severe. 

A firm, decided expression of opinion upon the safety of the patient's 
prospects of relief, often acts like magic in those cases where the 
attack originates in or is aggravated by mental or emotional causes. 
Balfour lays stress upon the importance of noticing the effect of exer- 
tion ; if this does not increase the palpitation and uneasiness, the case 
may safely be regarded as functional, and when the physician is cer- 
tain that the patient's heart is not the seat of organic disease, this clear 
statement has a very decided effect upon reducing the frequency and 
severity of the attacks. 

In the intervals between the attacks everything tending to depress 
the nervous system must be avoided, late hours especially, with excess 
in the use of tea, tobacco, and alcohol, and sexual excitement should 
be given up. Regularity in meals and in taking open-air exercise is 
of importance, as is also the avoidance of anything like brain over-work 
or high business pressure. This latter is of great importance, as func- 
tional disturbance may ultimately end in organic lesion if these causes 
be continued. 

Every departure from the highest standard of health must be sedu- 
lously attended to — ansemia met by iron and arsenic; plethora by 
exercise, saline purgatives, and corrected dietary ; dyspepsia by appro- 
priate remedies ; sleeplessness by sulphonal ; uterine ailments by local 
and general medication. Where the paroxysms have been caused by 
prolonged muscular exercise or overwork, absolute rest is imperative. 
Of drugs there are several which have been highly recommended for 



336 HEART, FATTY DEGENERATION OF. 

administration during the intervals between the attacks, after the cor- 
rection of any disordered condition which may have been present. 

Digitalis is the most potent of these, and its administration has been 
recommended upon high authority as a remedy for palpitation of a 
purely neurotic character. The writer has not only seen it fail in many 
cases, but he has found it to aggravate the condition sometimes. Un- 
fortunately there are no means by which its value can be decided in a 
given case until it is tried ; its effects should be closely watched, and 
its administration stopped after two weeks' trial if not satisfactory. 
The dose should not exceed 5 minims of the tincture. 

Bromide of potassium, in some instances, prevents attacks, but the 
writer's experience of its use leads him to believe that it should not be 
given for long periods without intermissions, and in these intermissions 
digitalis can be sometimes given with great advantage. 

Belladonna in minute doses, and strychnine in small doses have 
occasionally given good results, and iodide of potassium, 5 grains three 
times daily after meals, often affords the best results after failure of 
everything else. Antipyrine (5 grains) may hit where the before- 
mentioned drugs have failed. 

The writer has obtained much more uniformly successful results from 
the syr. ferri quininse et strych. phos., in drachm doses, than from any 
other remedies except the iodides, and he believes it to be the best 
routine treatment in simple or neurotic palpitation. Should there be 
any obscure organic lesion present, it cannot do harm and it is likely 
to do good. His plan is to give it for one month, and then to add 2 
minims of the tincture of strophanthus (1 : 20) to each dose while the 
treatment is continued for another month, after which the plain syrup 
is to be continued. The following mixture may be given : 

r*. — Acid, hydrobrom. dil 3 v .j- 

Tinct. belladonna? gij. 

Tinct. nucis vomicae . . . . . . . ^ij. 

Glycerini purif. ^jss. 

Tinct. aurantii ainar ad ^vj. — M. 

S. — A dessertspoonful in half a wineglassful of water three times a day before 
meals. 

Barium chloride may be given where cardiac pain is marked. The 
dose should not exceed I grain in pill or solution every eight hours. 

In those cases characterized by great frequency in the action of the 
heart, and known as instances of the " rapid heart," the above agents 
may be tried, often with benefit, but Sansom has shown that, in the 
really severe cases, treatment produces no effect. He particularly recom- 
mends the application of the continuous current over the region of the 
great nerve centres. (For Fainting, see Syncope.) 

HEART, Fatty Degeneration of 

Excluding those cases where this condition supervenes upon typhus, 
typhoid, or other fever, or wasting diseases, or phosphorous poisoning, 



HEART, FATTY DEGENERATION OF. 337 

where speedy recovery follows the removal of the cause, and the admin- 
istration of iron, stimulants, rest, and concentrated food, there remain 
those examples of the disease coming on, for the most part, in advanced 
life. 

Fatty degeneration appearing as the last scene in the progress of 
valvular lesions falls under the treatment suitable to these affections. 
Only the management of the disease occurring as a true senile degen- 
eration, or resulting from disease of the coronary arteries, need be here 
narrated. 

Being essentially an error of malnutrition the first indication should 
be to correct every error in living, and to prevent the slightest viola- 
tion of any health law. 

The diet should consist of wholesome concentrated food in moderate 
amounts administered at regular hours and frequently ; long fasts and 
hearty meals, especially late and hearty dinners being strictly forbidden. 
Well made strong beef- tea being an excellent cardiac stimulant, may be 
given between meals with advantage. Alcoholic stimulants are to be 
used in the smallest quantities, and are better avoided entirely except 
as medicinal agents at times of fainting or threatened collapse. Their 
moderate use as beverages generally does harm. 

Tobacco is injurious. Regular hours are essential ; " early to bed 
and early to rise " is a good rule. Purity of air breathed while asleep 
or awake is of importance. Where the patient's means and occupa- 
tion admit of it, he should be advised to spend the most of his spare 
time in the open air. Carriage exercise is to be recommended only 
when gentle walking causes fatigue. Climbing or very active work 
must be given up, rising ground and long flights of stairs are to be 
avoided, or only attempted with great deliberation. 

Everything that worries or annoys, and indeed all forms of brain 
work liable to produce excitement or exhaustion are to be cautioned 
against, and occupations or recreations conducive to quiet and content- 
ment should be recommended. By these means life may be prolonged 
without drugs. 

Remembering the danger of a fatal syncope supervening, rapidly 
diffusible stimulants like ammonia (sal volatile), whiskey, or ether 
should be within the reach of friends or attendants, and should be ad- 
ministered in diluted form after the horizontal position is adopted. 
Nitrite of amyl may be useful. For these emergencies a mixture like 
the following is of use : 

R. — Spt. setheris ^j. 

Tinct. belladonna? ^ij. 

Spt. amnion, aromat. ^j. 

Tinct. zingiberis gvj. — M. 

S. — A teaspoonful to be taken in a wineglassful of water when the difficulty 
of breathing or palpitation is severe. 



338 HEART, HYPERTROPHY OP. 

Where cardiac collapse and breathlessness do not soon pass off a 
hypodermic of 2 minims of liquor atropine (1 : 100) may be given. 

Of drugs intended to strengthen the muscular fibre many have been 
highly recommended for constant administration upon empirical or 
rational grounds. In cases of pure fatty degeneration of the heart 
uncomplicated by valvular lesion, hypertrophy or dilatation, the ordi- 
nary cardiac tonics — digitalis, strophanthus, sparteine, convallaria, etc., 
are practically useless, and may do some mischief. 

Phosphorus and arsenic — drugs which in large doses cause fatty 
degeneration of the heart — have been praised. The writer has never 
seen any decided benefit follow their use, and he has ceased to prescribe 
them. Ergot is of doubtful value, but iodides are of very great use, 
especially in those cases associated with pain and cardiac distress. 

Iron and strychnine, if tolerated, are not open to any objection, and 
may be freely administered with a fair prospect of success. 

Quain speaks highly of the dialyzed iron, and his authority upon 
any point in the treatment of this disease should be final. 

Easton's or Fellow's syrup may be taken for long periods with ad- 
vantage, and cod-liver oil, with Kepler's malt extract, may be given 
at the same time. 

General massage would appear upon theoretical grounds to be worthy 
of a trial, and the writer has resolved to give it a fair trial when a 
suitable opportunity occurs. Galvanism, which has been recommended, 
is an agent which the wise physician may well hesitate to employ until 
we know more about its effects upon the healthy heart. 

The condition of the skin, kidneys, bowels, and all the excretory 
organs is of vital importance. 

Fatty growth on the heart, or fatty infiltration, is a condition though 
widely differing from the above, nevertheless should be treated pretty 
much upon the general principles just enumerated for fatty degenera- 
tion. Dietary being, however, a matter of the most important consid- 
eration, the reader is referred to the remarks under obesity. Oertel's 
method, consisting of a combination of diet and exercise treatment, in 
which mountain climbing is a prominent feature, has given excellent 
results in some cases. It will be referred to under valvular lesions of 
the heart and under Obesity. 

HEART, Hypertrophy of. 

In the Lumleian Lectures, Broadbent ably puts the question of treat- 
ment in this condition in a nutshell when he says : " The treatment of 
hypertrophy as such has always appeared to me to be out of place." 

The symptoms which may strike the student as calling for remedies 
are often or irregular or painful palpitation, precordial distress, etc., and 
these, even in aortic obstruction with enormous hypertrophy, may be but 
evidence of the beginning of failing compensation, and the agents de- 
manded are not sedatives, but cardiac tonics and rest. Belladonna 



LESIONS OF. 339 

plaster applied and worn over the cardiac area is always a safe ano- 
dyne under nearly all circumstances. 

In those rare cases of hypertrophy not associated with valvular affec- 
tion small doses of atropine have been used, but this agent is not to be 
pushed if it fails to give speedy relief. Where there is fibroid degen- 
eration or contraction of the kidney, the only sound plan to pursue is 
to treat the primary affection by increasing every possible means of 
producing elimination of the retained excrementitious products allowed 
to accumulate in the system, and to cause contraction of the capillaries 
and small vessels. 

HEART, Valvular Lesions of. 

There is hardly any department of treatment requiring more serious 
study than that of the management of cardiac valvular diseases. There 
is none where a close attention to details will better repay the practi- 
tioner. His experience is, indeed, limited, and his treatment of these 
cases unsuccessful, who cannot at once call up instances where he has 
seen life prolonged for many years, and where he has felt that by the 
judicious use of remedies patients have been "called back" from the 
brink of the grave. 

Under endocarditis is mentioned the treatment of the condition out 
of which the valvular affection arises. After recovery from the rheu- 
matic attack and its cardiac complication, the value of prolonged rest 
is insisted upon as the best hope of preventing permanent valve mis- 
chief. Iodide of potassium at this time may be hopefully administered. 

If after a time, when the patient has returned to his usual occupa- 
tion, the physician finds that the permanence of the murmur tells that 
obstruction or regurgitation has resulted, the question of treatment 
crops up. There is some danger that an error may be committed at 
this stage. The appreciation of the mischief aud danger of dosing 
every patient in whom a cardiac murmur is audible marks a distinct 
advance in cardiac therapeutics. Nevertheless there are not wanting 
signs which show that the pendulum has swung too far. If the dictum 
holds good that cardiac tonics should not be prescribed until failing 
compensation is evident, then, of course, nothing should be done in the 
early stages. This is true in the great majority of cases coming under 
the eye of the physician for the first time, but occasionally he meets 
with symptoms clearly indicating that the ventricle has not yet suffi- 
ciently responded to the extra demands made upon it. In other words, 
the case falls under his observation before compensation has had time 
to occur. He will probably find in such cases that the patient has re- 
sumed his usual avocation too early, or that there may be some serious 
error in nutrition. 

The treatment of such a case must be carried out by the judicious 
use of cardiac and other tonics, with rest. The condition closely resem- 
bles that of a patient who had long been the subject of a valvular 



340 HEART, VALVULAR LESIONS OF. 

lesion, and in whom compensation is beginning to show signs of failure. 
The precordial pain, palpitation, and breathlessness may be regarded 
as indications for treatment just as if occurring in an old case. Their 
management will be considered when describing the treatment of fail- 
ing compensation presently. 

As a rule, however, the victims of valvular lesions do not chance to 
come often under the notice of the physician at this early stage. 

Frequently, in the course of a routine examination, a regurgitant or 
or obstructive murmur is discovered in a patient who is hardly con- 
scious that he has a heart, so perfectly has the hypertrophy enabled 
the ventricle to meet the demands made by increased resistance. It is 
now accepted as a general rule, and there should be few exceptions to 
it, that the exhibition of cardiac tonic is not only uncalled for, but may 
do serious mischief in such a case. Indeed, it has been stated that the 
greatest misfortune which can overtake such a patient is to fall into 
the hands of a physician, and it cannot be doubted that often ignorance 
is bliss under such circumstances. 

To remove the diseased condition is obviously an impossibility in the 
present state of our knowledge and with the present resources of our 
art. Were such a result attainable it would be a serious question to 
decide upon disturbing the perfectly-balanced compensation. Conse- 
quently, the most that one is justified in doing is to consider what steps, 
if any, are necessary to maintain the perfect adjustment. A little 
reflection will show that the adjustment will probably be best kept up 
by a continuous adherence to those rules or habits under the influence 
of which such complete compensation has already developed. This 
should be the key-note to our advice and management of the case. 
Nevertheless, the physician should make minute inquiry into the habits 
and mode of life led by the patient. It is just possible that compensa- 
tion has taken place, in spite of the violation of some law of health, 
and that continued transgression may be certain to ultimately induce 
failure as the patient gets older. Hence, errors are to be judiciously 
sought for and wisely remedied without exciting the alarm of the 
patient, who should not be led to regard himself as an invalid or a 
cracked pitcher which every contact with the rough world may shiver 
into fragments. 

Temperance in all things is essential to a prolonged career under 
such circumstances. Excess in alcohol and tobacco, sexual excitement, 
severe business high pressure, mental over-strain and worry, and pro- 
longed severe muscular exertion should be avoided. A fair amount of 
muscular exercise is not only unobjectionable, but is really essential, in 
order to keep the cardiac muscle in a healthy condition. The physi- 
cian is more liable to err in limiting than in encouraging the necessary 
amount of exercise. Walking may safely be indulged in to any rea- 
sonable extent. Even mild gymnastic exercises are productive of good 
under certain restrictions. Short spurts of running, lifting heavy 
weights, and violent quick movements are to be forbidden. 



HEART, VALVULAR LESIONS OF. 341 

Everything likely to maintain a high standard of health should 
be advised, and a good liberal mixed diet prescribed, such as expe- 
rience has proved to the patient to be most acceptable and sustaining. 
The writing out of a diet table for the subject of a valvular lesion in 
which compensation has taken place is a mistake. As far as possible, 
the patient should be guided by his own instincts and experience in 
eating, avoiding much tea and all indigestible substances. 

The earliest symptoms of failing compensation should be looked for 
with a watchful eye by the physician. They are the real indications 
for active treatment, and early failure of compensation generally is 
easily remedied. Perhaps this is the best example furnished by prac- 
tical therapeutics of the truth of the adage that " a stitch in time saves 
nine." 

Palpitation, cardiac pain, breathlessness, dyspnoea, anaemia, blueness 
of the extremities, oedema of the feet, passive congestions of the 
liver, stomach, intestines and kidneys, and slight albuminuria are to 
be regarded, not as so many different symptoms, each requiring its 
specific remedy, but as the direct outcome of one cause, which requires 
remedying. 

Before mentioning the different drugs which may be used to strengthen 
and build up again the debilitated muscular walls of the dilated ven- 
tricle, it may be advisable to consider other important aids to treatment, 
as diet, exercise, etc. 

The exact value affected and the nature of the affection, whether 
resulting in obstruction or regurgitation, are of comparatively minor 
importance, the secondary changes in the cardiac muscle and in the 
ventricular cavities demanding primary consideration. 

Diet should be of the most nutritious and sustaining character, 
consisting of a fair amount of nitrogenous food, with small propor- 
tion of fats and saccharine matter. It has been pointed out, in detail- 
ing the lines for the management of cases of valvular lesion in which 
complete compensation has taken place, that there is a serious objec- 
tion to prescribing a fixed diet or bill of fare. In the treatment of 
the cases now under consideration there are stronger reasons why this 
should not be allowed. A theoretically constructed diet table for 
failiDg compensation is very good upon paper, but at the bedside it is 
of little use. 

Dyspepsia depending upon passive congestion of the gastric mucous 
membrane is a pretty constant early symptom, and it resents attempts 
to sustain life by obedience to hard and fast lines. For this reason 
rectal feeding is of vital importance in many cases. 

Leube's bland nutritious enema suits such cases well. One and a 
half ounces of muscular fibre is beaten into a smooth paste, with $ 
ounce of finely- chopped pancreas free from fat, in a warm mortar, 
with a little lukewarm water to give suitable consistence. The whole 
may be injected every six hours. Peptonized beef tea or Koberts's 
peptonized milk gruel may be used. Cold milk is added to an equal 



342 HEAKT, VALVULAR LESIONS OF. 

quantity of thick oatmeal gruel, at a temperature of 212° F. About 
three-fourths of a teaspoonful of liquor paDcreaticus and 5 grains of 
bicarbonate of soda are added to 5 ounces of the mixture. 

Sansom recommends an easily-prepared enema, consisting of 2 ounces 
of warm milk shaken up in a bottle with 1 ounce of cod-liver oil. He 
says : " I feel sure, from my experience, that lives may be prolonged 
and crises tided over by such supplementary alimentation " — a state- 
ment that the writer's experience has proved true. 

The most convenient of all methods of rectal feeding, when expense 
is no object, is the use of a good nutrient suppository. It is, of course, 
understood that rectal feeding is only to be employed in those advanced 
cases where the patients are unable to eat and digest. In the case of 
children, excellent results may be obtained by the inunction of cod- 
liver oil over the abdomen. 

Oertel has introduced a method of treating failing compensation by 
a combination of diet and exercise, which may be now referred to. 
Exercise was formerly considered as contra-indicated. The intro- 
duction of this treatment may be regarded as a protest against the 
practice of enforced rest in chronic valvular lesions. Oertel tried 
it first in cases of fatty heart associated with general obesity, and his 
results were so strikiug that he applied the treatment to valvular 
lesions. 

The rationale of the plan is based upon the rather doubtful assump- 
tion that the blood in these cases contains an undue proportion of water. 
Hence he believes, if this can be removed by a diminished supply and 
increased excretion, the work which the heart is called upon' to do and 
the congestion of organs will be lessened. Of all the methods for 
increasing the elimination of water, he has proved that none equal 
mountain climbing. About one quart of water, he found, was excreted 
by the skin and lungs after an ascent of over 1000 feet, made in a climb 
of rather less than four hours, the urine not being materially altered in 
quantity. At the same time, the heart is stimulated to more forcible 
contractions, and the muscular exercise has powerful influence, through 
the relations of the great veins to the fascia, in quickening the 
venous and arterial circulations. The result is, that in the long run 
a genuine and healthy hypertrophy of the cardiac muscular fibre takes 
place. 

The quantity of fluid ingested he reduces to an amount under one 
quart daily, inclusive of that contained in the solid constituents of 
the food. 

The diet should be highly nitrogenous, consisting chiefly of proteids, 
with a little fat and a limited amount of carbohydrates. 

He lays down a strict diet table, in which the total food for the 
twenty-four hours amounts to about : 5 i ounces of albumin, 1 ounce 
of fat, 3 ounces of carbohydrates, 35 ounces of water. 

Of the 35 ounces of water a little less than half is contained in the 



HEART, VALVULAR LESIONS OF. 343 

solid food, and a little more (about 1 pint) is to be given as drink. 
Thirst may be relieved by frequent gargling with water. 

The following is a summary of the articles included in such a diet, 
with the approximate quantities in English weights and measures : 

Morning meal: Coffee 4£ ounces, milk 1 ounce, sugar 77 grains 
wheaten bread 1J- ounces. 

Mid-day meal: Soup 3 ounces, roast or boiled beef, or veal, or 
game, or lean poultry 7 to 8 ounces, fresh salad 1 ounce, bread 1 
ounce, never to exceed 3 ounces, fruit 3 to 6 ounces, a little fish if 
desired. Light wine, 6 to 8 ounces if no fruit or if very hot weather 
otherwise no fluid with this meal. 

Afternoon meal : Coffee 3J ounces, milk 1 ounce, sugar 77 
grains, water 2 ounces, never more than 6 ounces, bread 1 ounce 
(exceptionally). 

Evening meal : Wine 7 ounces, water 2 ounces, 1 or 2 eggs, roast 
meat 5 ounces, salad 1 ounce. 

Since the above dietary is intended for those cases of fatty heart 
associated with obesity, its use is a serious mistake when applied to 
cases of ordinary failing compensation in which obesity is not a promi- 
nant symptom. It is inserted here to give a bird's-eye view of 
Oertel's plan of practice. (See under Obesity.) 

This method has been received by different authorities with very 
varying degrees of favor or hostility. The writer has had no experi- 
ence of its working whatever, though he has had ample proof of the 
benefits of moderate exercise and very mild gymnastics in failing 
compensation. 

From a. very careful study of the experiences of others it would 
appear that in selected cases it is a valuable addition to cardiac thera- 
peutics. The cases in which it gives best results are in very fat sub- 
jects, in the anaemic, and in those complicated with gout, as pointed 
out by Sansom. 

Recently Oertel has admitted that it should not be attempted where 
there is very serious incompetence of the cardiac muscular fibre, or 
where there is atheroma, nor should it be persisted in where dyspnoea 
is increased, or the excretion of urine diminished under its use. 

Modifications of the plan may be carried out by regulating the diet 
so as to materially diminish the amount of fluids consumed, and to 
increase the amount of urea and water eliminated by means of the 
hot-air bath, hot packs, and hypodermic injections of pilocarpine, 
combined with the use of the cardiac tonics to be presently mentioned. 

If to these be added systematic and judicious muscular exercise 
upon level ground, and a careful and thorough course of massage, all 
the benefits of Oertel's treatment, without its serious dangers, may be 
procured. In concluding this portion of the description of the man- 
agement of failing compensation, the writer would venture to suggest 
that unless the physician has had a very extended experience in the 
treatment of valvular lesions he will be wise in refraining from pre- 



344 HEART, VALVULAR LESIONS OF. 

scribing Oertel's practice without sharing some of the responsibility 
with a medical brother. 

The plan of massage and hot douches, as practised at Aix-les-Bains 
and recommended by Sansom, has been productive of much good in 
the experience of the writer, who has had patients return very much 
improved after a short course of Dr. Blanc's treatment, 

Karell's absolute milk diet treatment has been carefully tried at 
the Dorpat Clinic, with results meriting some confidence in cases of 
advanced failure of compensation. After a few days upon a diet 
consisting exclusively of milk the following results began to come under 
notice, and continued for months : The quantity of urine rapidly in- 
creased, albumin diminished and disappeared, the pulse rate fell to 
normal, congestions faded away, and the general condition surprisingly 
improved. Upon a diet consisting prineijjally of milk the patients 
were found to gradually go from bad to worse ; so that if this treat- 
ment is to be tried, no other food whatever should be given. Milk in 
small quantities, given at short intervals, must be persisted in for some 
time until the ingestion is carried to the fullest possible extent. In a 
few cases in which this method was tried by the writer it did not prove 
satisfactory, and had to be abandoned owing to gastric complications. 
It would, however, be well to give the plan a further trial in those 
cases where cardiac tonics cannot be borne, and to combine with it a 
thorough course of massage. 

Treatment by drugs. — After evidence of failing power in the cardiac 
muscular fibre has been established, the question of the administration 
of cadiac tonics should immediately suggest itself. 

One point may be here mentioned, the consideration of which may 
save the physician from falling into a not uncommon error. Remem- 
bering that a patient (in whom perfect compensation may exist) lives 
in a state of not very stable equilibrium, the transitory disturbances 
caused by severe mental emotions or other trying causes should not 
be mistaken for the onset of permanent failing compensation. In 
aortic disease especially, such passing disturbances may give rise to 
painful palpitations and distress where great hypertrophy exists. 
The passing symptoms in such cases would probably be aggravated by 
digitalis and other cardiac tonics. Sedatives like aconite, veratrum 
viride, bromides, or iodides afford marked relief. Their use should 
not be continued for any length of time. The permanence of the 
symptoms points to loss of muscular power rather than to altered 
innervation, and then cardiac tonics are called for. 

A combination like the following gives speedy relief where there is 
a strong hypertrophy : 

R. — Tinct. aconiti Hlxij. 

Potassii bromidi ^ij. 

Spt. aether, nitrosi . . . . . . • 3 v. 

Aquse camph . .ad Jiij. — M. 

S. — A teaspoonful to be taken every two hours. 



HEART, VALVULAR LESIONS OF. 345 

When palpitation, precordial pain, breathlessness, pulmonary or 
other congestion, and commencing oedema show themselves in chronic 
valvular lesions, cardiac tonics should be given wihout loss of time. 

Digitalis, notwithstanding the introduction of a host of rivals, at 
present stand-s, and probably for all time will stand, as the most relia- 
ble member of the group of cardiac and vascular tonics. By acting 
as a stimulant to the cardiac fibre, it produces slower and stronger 
contractions, allowing the left ventricle to drive a larger volume of 
blood into the aorta at each stroke. At the same time it causes a 
more perfect adaptation of the segments of the mitral valve by less- 
ening the size of the orifice. It prolongs the diastole, thus permitting 
the more complete filling of the ventricle in mitral stenosis, and at the 
same time it strengthens the power of the auricle. The prolongation 
of the diastole benefits the circulation in the cardiac fibres and im- 
proves their nutrition. 

Wood regards digitalis as a heart food and tonic, and not as a 
cardiac stimulent. According to Romberg's new views about the im- 
portance of regarding the myocardium and not the ganglia as the 
automatic motor of the circulation, we must come to the conclusion 
that the drug acts strongly upon this portion of the cardiac apparatus 
also. 

By causing increased contraction of the small arteries and capillaries, 
digitalis raises the blood pressure and so affects the lymphatic and 
venous circulations as to. exert a powerful influence upon dropsy. 
Through its effect upon the vessels, it also acts as a powerful diuretic, 
and may be made to cause enormous increase in the amount of urine 
secreted, especially when the patient is almost "water-logged." 

These valuable actions of digitalis may be successfully employed in 
valvular lesions with failing compensation, and by its intelligent use 
life may be prolonged for indefinite periods under conditions of com- 
parative comfort. 

The old notion that this drug acted as a cardiac sedative still to a 
very limited extent survives, and has been a serious impediment to 
successful treatment. Its haphazard administration has sometimes led 
to bad results, nevertheless the following statement inade by the writer 
in an address a few years ago does not say too much for the 
remedy : 

"When I first commenced the study of medicine I remember well 
my introduction to foxglove, which even at that recent period was re- 
garded as a narcotic, and its virtues were impressed upon me with all 
the dogma of authority, especially its great power as a cardiac sedative. 
I was informed and taught that it would subdue a Hercules, and was 
of great value in weakening the pulse and soothing the heart when it 
was acting too strongly but that it was dangerous, and should not be 
used when the pulse was weak and irregular. We now understand its 
action, and employ this drug daily as a cardiac tonic in imperfect 
compensation, watching its influence upon the cardiac ganglia, meas- 

23 



346 HEAET, VALVULAE LESIONS OF. 

uring its effect upon the lengthening of the diastolic pause, and obser- 
ving how the wearied cardiac muscle gains new life and vigor by the 
increased coronary nourishment administersd during the prolonged 
diastole. Though often we may be puzzled and disappointed, owing 
to the many complex disturbing influences at work, still constantly we 
shall find cases in which we can use this tried and faithful weapon 
with an accuracy approaching the mathematical. " 

From these remarks it will be seen that the dose of digitalis will 
vary somewhat according to the condition of the patient and the nature 
of the lesion and other considerations to be mentioned. 

Various opinions prevail regarding the relative values of the dif- 
ferent preparations of the drug. The tincture of the U. S. P. (1 grain 
in 6f minims) is the most convenient form, but where a purely 
cardiac tonic effect is only required the infusion is to be preferred. 

The tincture, however, has the great advantage of being more 
powerfully diuretic, and as dropsy is a very constant feature in the 
late stages of failing compensation, the tincture is the best preparation 
in the majority of instances. 

Owing to the danger of accumulation taking place the action of the 
drug should be watched for a week or two with care. As a rule in 
moderate doses ( 5 to 10 minims ) it may be administered for years 
without producing any unpleasant symptoms. As long as the quantity 
of urine excreted is of fair amount the drug is eliminated by the kid- 
neys, and its cumulative action is not experienced. Where large 
doses are considered necessary the patient should be kept in the hori- 
zontal position, and the administration should be stopped as soon as 
the blood pressure rises so high as to seriously diminish the amount of 
urine. 

Iron may be combined with digitalis nearly always with marked 
advantage, as anaemia is commonly present. The combination is not 
an elegant one owing to the incompatibility of its tannin, but it is 
nevertheless a valuable therapeutic mixture : 



Be . — Tinct. digitalis 
Tinct. ferri chlor. 
Spt. chloroform! 
Glycerini purif. . 
Aquse destil. 



. Ulclx. 

• 3iij- 

• 3ij- 

ad J iv.— M. 



S. — A teaspoonful in a wineglassful of water three times a day after meals. 

The relative value of digitalis in the different valvular lesions may 
be briefly stated. 

In mitral regurgitation, the effects of the drug are seen to best 
advantage. As already stated, it lengthens the diastole, and gives a 
longer period for cardiac repose and nourishment of the muscular 
fibre. It diminishes the size of the mitral orifice, and ensures the 
more complete filling and subsequent emptying of the ventricle into 



347 

the aorta. By its similar tonic action upon the right ventrile, it 
enables it to overcome the increased resistance to the pulmonary cir- 
culation, and lung congestion disappears. The increased ventricular 
power thus gained, together with its tonic effect upon the vessels, 
reduces the pressure in the venous system, and dissipates the general 
congestion of organs and dropsy. The blood pressure rises, and the 
pulse slows, while it gains in force and regularity. 

In mitral stenosis, the action of digitalis is not so satisfactory. The 
experience of the writer in hospital and private practice has led him 
to believe that mitral stenosis without regurgitation is a comparatively 
rare affection. In the great majority of cases the narrow chink or 
funnel-shaped mitral orifice permits of regurgitation. In considering 
such cases, it becomes a question of the degree of obstruction and its 
relation to the accompanying regurgitation. Is there more of obstruc- 
tion than of regurgitation in the affection ? He has come to a conclu- 
sion that may be formulated in the following therapeutic rule : In 
proportion to the extent of the obstructive lesion, so will the effect of 
digitalis be disappointing ; and, conversely, the more regurgitation 
taking place, the more improvement may be expected from digitalis. 

In pure obstruction the drug often cannot be tolerated, and though 
sometimes it appears to strengthen the dilated auricle, and by length- 
ening diastole to give the blood a longer time to flow through the 
narrow valve, nevertheless it may increase irregularity of the pulse 
and cardiac distress. It. should, however, be given in every case a 
fair trial, and, after failure, other cardiac tonics may be tried. 

In aortic obstruction, if digitalis be given too early— i.e., before fail- 
ure of compensation has taken place — very serious disturbance maybe 
caused by it, owing to the enormous hypertrophy commonly present. 
Where there is marked failure of the enlarged ventricle to drive the 
blood through the narrowed aortic valve, digitalis acts sometimes like 
a charm. It may always be counted upon in such cases, but more 
care is needed in its administration than if the affection was mitral 
regurgitation. 

After the ventriular strength has been restored and compensation 
again adjusted, the use of the drug should be stopped. It may, 
however, be again commenced as soon as evidence points to ventricular 
weakness, the prolonged, continuous rise in blood pressure being un- 
desirable in aortic stenosis, owing, as suggested by Bramwell, to the 
risk of rupture of the diseased peripheral vessels. 

In aortic regurgitation, the case is not so easily made out in favor 
of digitalis, and there are still sharp differences of opinion regarding 
the benefits and dangers of the drug in this affection. 

Brunton, with his usual clearness and force, has ably defined the 
indications and contra-indications. He points out that, owing to the 
diseased valves failing to close in diastole, the arterial system is open 
at both ends, and thus a fatal syncope may be induced by a fall in 
blood pressure. This occurs in a small percentage of cases, and the 



348 HEAET, VALVULAR LESIONS OF. 

tendency to it cannot be wisely overlooked. Anything which prolongs 
the period during which the backward flow of the stream into the 
ventricle is taking place increases the danger of syncope. Hence 
digitalis, by prolonging the diastole, may increase this danger. He 
points out how such danger may be minimized during the adminis- 
tration of the drug, by insisting upon the patient keeping in the hori- 
zontal position, with the head lowered. 

When, however, the change in the left ventricle proceeds so far as 
to permit of mitral regurgitation by imperfect closure of the mitral 
curtains, digitalis is called for. Where mitral regurgitation takes 
place from the first through structural alterations in the auriculo- 
ventricular valve, the drug gives excellent results. 

Again, in cases of pure aortic regurgitation, without any mitral 
regurgitation at the later stages, where failing compensation is marked 
and the pulse becomes frequent, irregular, and weak, the failing 
cardiac mnscle calls for digitalis. Pulmonary embarrassment, breath- 
lessness, congestion of organs, and dropsy disappear under its use. 
The drug should be discontinued as soon as compensation is thorough- 
ly established. 

Fiirbringer recently states that he does not know of a single ana- 
tomical contra-indication to the use of digitalis. 

The other cardiac tonics which have been of late years employed 
as substitutes or aids to digitalis, are strophanthus, caffeine, casca, 
convallaria, adonis vernalis, squill, sparteine, chloride of barium, 
senega, arsenic, and strychnine. 

From time to time each of these has been lauded as a remedy cer- 
tain to displace digitalis ; too often the statement has been made upon 
the experience gained in a few cases in which digitalis has been found 
to disagree with the patient's appetite or digestion. All one can say 
is that, in the present state of our knowledge of the relative values of 
the members of the group, given a case of failing compensation, the 
first drug to prescribe is digitalis. When it fails strophanthus may 
be tried, then caffeine and sparteine. Though much has been written 
upon these drugs, the action of no -member of the group has been as 
fully worked out as in the case of digitalis. Probably the experience 
of the writer has been that of nearly every physician in this matter. 
It may be summed up by saying that when in the management of a 
serious case of failing compensation, pulmonary engorgement and a 
halting ventricle warn us that unless we come to close quarters with 
the enemy our patient must succumb, then every other drug is thrown 
aside and we invariably fall back upon our tried and trusty weapon 
— digitalis. The serious and pressing nature of the case does not jus- 
tify one in experimenting with the different members of the group of 
cardiac tonics, hence the experience at present gained is for the most 
part accumulated from cases in which these drugs have been admin- 
istered in the earlier stages of failing cardiac power. The results of 



HEART, VALVULAR LESIONS OF. 349 

this system of skirmishing "at long range" can hardly be judged side 
by side with the records of the older cardiac tonic. 

There are, however, several well-marked differences in the actions 
of some of these remedies already worked out by the pharmacologist. 
Thus strophanthus has little if any diuretic action, certainly it has 
less diuretic action than digitalis, though some observers have recorded 
instances where it markedly increased the amount of urine. It acts 
more powerfully upon the heart than digitalis does, and it has less 
action upon the arterioles, the rise of blood pressure being nearly all 
owing to its cardiac action, unlike what happens with digitalis. 

The brilliant researches of Fraser have recently shown that the 
action of strophanthin, in minimum lethal doses, shows itself by great 
increase in the stength and in the duration of systolic contraction, and 
the ultimate standstill of the heart in this contraction passing into 
rigor mortis. He points out that this increased duration of contraction, 
with lessening of the dilatation and capacity of the chambers, is not 
the action likely to be serviceable in weak conditions of the organ or 
in the existance of disabling lesions. By giving smaller doses he 
demonstrated great prolongation of the diastolic pause, though the 
interrupting systolic contractions were strong, and completely emptied 
the ventricles of their large accumulation of blood. Thus he has 
solved what would have been a problem frought with enormous diffi- 
culties and fallacies at the bed-side i. e., that strophanthus greatly in- 
creases the working capacity of the heart, by increasing both diastole 
and systole through its stimulating effect upon the muscular fibre 
itself and its influence upon a portion of the intra-cardiac nerve 
apparatus. 

It certainly has this advantage over digitalis, that it does not possess 
any cumulative action ; but it sometimes causes gastric and intestinal 
disturbances. The following extract, taken from the writer's last 
edition of Materia Medica and Therapeutics, gives his experience of 
the drug: 

"During this period the writer has been using it extensively in 
hospital and private practice, and closely watching the reports fur- 
nished by clinical observers in America and Europe, and these reports 
in the main correspond with his own observation that, though the 
drug is a powerful cardiac tonic of great value, it is, upon the whole, 
inferior to digitalis, and not less dangerous. It is, however, a most 
valuable addition to therapeutics, especially as it can be given in those 
cases which one constantly meets with where digitalis cannot be tol- 
erated, and the writer has noticed that this oftener occurs in mitral 
obstuction, with a very narrow orifice. Moreover, strophanthus is 
invaluable as a remedy to be given in the intervals, when it is found 
wise to suspeud digitalis, and in those cases where the latter drug 
causes trouble by its effects upon the capillaries. It will be found a 
wise and often highly satisfactory plan to give digitalis for two months 
and then strophanthus, combined with syr. fer. quin. et strych. phos., 



350 HEART, VALVULAR LESIONS OF. 

for one month, in ordinary cases of failing compensation. The reports 
of the drug differ much in details, and this arises from the difference 
in strength of the preparation used and of the seeds imported. 
Dujardin-Beaumetz gives large doses, and affirms that the tincture is 
diuretic, but that strophanthin is not. The dose of strophanthin is 
0.002 grain. There are at least four tinctures of the seeds, devised, 
one should think, to produce confusion. 1. Frazer's original tincture, 
same strength as digitalis (1 : 8), the dose of which is 2 minims. 2. 
Frazer's recent tincture, which is the tincture accepted by the B.P.C. 
( 1 : 20 ), ( in this the fatty matter is extracted with ether ) ; dose, 
5 to 10 minims. This is now the official B.P. tincture. 3. Bardet's 
French tincture, (1:5); it is green, the fatty matter not being 
extracted. Dose, 1 minim. 4. Catillon's French tincture (1 : 5) 
made like, No. 2. Dose, 1 minim. The B. P. tincture should only 
be used, and in doses not exceeding 5 minims. When the green, 
inert fatty matter existing in the seeds is not removed the drug 
excites troublesome gastric derangement." 

Professor Frazer's late researches inspire us with the hope that as 
we become more familiar with the exact therapeutic action and dose 
of strophanthus, we may be able to so graduate the dose as to prolong 
systole without lengthening the diastole. When this can be done with 
safety and precision the treatment of aortic regurgitation will be lifted 
out of its present rather unsatisfactory position. 

Caffeine. — There is still much difference of opinion regarding the 
cardiac tonic action of this drug, some authorities going so far as to 
declare that it possesses no digitalis like action upon the heart, and 
that its diuretic action is simply owing to its local influence on the 
renal epithelium. Other observers report very satisfactory results in 
failing compensation, and the writer believes that he has seen excellent 
results from the administraion of 3 to 5 grain doses of the citrate in 
mitral regurgitation, with much anasarca and congestion of organs, 
where digitalis was not well borne. 

One advantage it certainly possesses over digitalis which will con- 
tinue to give it some position in cardiac therapeutics — i. e., that its 
diuretic action is more rapid than that of the old-established remedy 
— an advantage of great importance in some cases where time is of 
primary consideration. 

Convallaria does possess some cardiac tonic powers, but the test of 
time is telling seriously against its claims as a substitute for digitalis. 
At present the consensus of opinion is pointing to a rule which is 
being gradually formulated that the drug should only be tried when 
digitalis fails. 

In mitral stenosis and aortic regurgitation it has often been found 
to slow the pulse, strengthen the ventricular contractions, relieve 
dyspnoea markedly, and remove dropsy. It may be given in combina- 
tion with caffeine in these cases with advantage. 

Sparteine produces rapid cardiac tonic effects. It acts in most 



HEART, VALVULAR' LESIONS OF. 351 

respects like digitalis, but is much quicker in its action, and hence 
where a rapid result is required it may be said to have no rival which 
is at the same time safe in full doses. Three grains may be given 
every six or eight hours. Its diuretic actions is markedly inferior to 
that of digitalis. Given a case of rapidly failing compensation, spar- 
teine may be ordered in full doses immediately, and after a few days, 
when its affect appears to be on the wane, digitalis may be admin- 
istered with much benefit. Like all the other members of the group, 
it may be given with advantage during the intervals in which digitalis 
is suspended during a prolonged course of that drug. 

Chloride of barium has recently been much praised as a cardiac 
tonic. The writer has had no experience of the drug, and can only 
speak from the published reports of those who have tried it in failing 
compensation. These reports in the case of new drugs are more or 
less neutralized by the experience of the next crop of investigators, 
but allowing for this the remedy under notice will probably continue 
to gain confidence. 

It possesses power closely resembling digitalis. It slows the pulse 
very markedly, and regulates its action, raises the blood pressure by 
its cardiac and vascular stimulation in doses of one drachm of a 1 per 
cent, solution, which is tasteless and unirritating to the stomach. It 
has been given in all forms of valvular lesion, and no ill effects have 
been noticed. Most observers have stated that it relieves cardiac pain, 
and is a mild diuretic. 

Mitchell Bruce, in writing upon the treatment of failing compensa- 
tion in children, has pointed out the great value of hypodermic injec- 
tions of strychnine in 1 per cent, solution, which, he states, has in 
some instances an effect little short of the marvellous in restoring the 
action of the ventricles. This is a point of the greatest importance 
since the action of digitalis is slow, and in urgent cases strychnine 
should be given hypodermically while awaiting the full action of 
digitalis. 

Squill, senega, adonis vernalis, adonis aestivalis, cactus grandiflorus, 
carduus marine, coca, apocynum cannabinum, and many other cardiac 
tonics have been from time to time used in failing compensation, but 
it remains to be proved that they possess any advantages over those 
already discussed. 

So many points remain for " clearing up " in the action and thera- 
peutics of the better known members of the cardiac tonic group, that 
the ceaseless introduction of new rivals is actually becoming a serious 
barrier to therapeutic progress. At the head of the entire list still 
stands digitalis, and of all those below it, the most that can be said of 
them is that they are of value when it fails or disagrees, and that they 
may be administered with advantage when it is considered wise or 
expedient to leave off its use for short periods. 

Arsenic appears to be of special use w'here there is evidence of 
degeneration of the cardiac fibre having taken place to any extent. 



352 HEART, VALVULAR LESIONS OF. 

It may then be combined with strychnine and iron. Some authorities 
recommend a combination of the various cardiac tonics at the same 
time, but the more we know of cardiac physiology the less likely is a 
conglomeration of crude drugs to meet the indications of the case. 

At this place no mention is made of ether, alcohol, ammonia, etc., 
which are ofteu classified as cardiac tonics, bnt it is needless to say, 
they possess no such action, being simply cardiac stimulants whose 
place in medicine is to be administered when a rapid stimulation of 
the feeble cardiac muscle is required, while other remedial agents are 
getting time to exert their more permanent influence. 

There are various prominant symptoms or complications which often 
arise during the later stages of valvular lesions, the treatment of 
which may be briefly referred to. 

Bearing in mind that these symptoms for the most part take their 
origin in the disturbed balance produced by failure in the cardiac 
muscular fibre, their successful management will generally mean the 
administration of cardiac tonics. There are, however, other remedies 
which the physician may call to his aid when the urgency of the 
symptoms does not justify him in waiting for the comparatively slow 
action of these drugs. 

Dropsy may threaten the patient's life from oedema of the lungs 
before digitalis has time to act, and the general rules laid down in 
speaking of the treatment of Bright's disease are for the most part 
applicable to the anasarca which results from valvular trouble. In 
the former case, however, the kidneys being more or less crippled in 
their action, diuretics are of comparatively little avail, and may be 
even dangerous, while in cardiac dropsy the physician can for the 
most part count upon their co-operation. 

Calomel often acts as a powerful diuretic in these cases, 5 grains 
sometimes producing very considerable increase in the amount of urine. 
Occasionally serious prostration has followed its administration, and 
it should not be given where there is any renal disease. 

Iodide of potassium is valuable. It may be combined with great 
advantage with other diuretics and with digitalis. The following is a 
good combination : 

R. 



-Potassii iodidi . 




giss. 


Spt. ammon. aroraat. 


. 


3iv. 


Tinct. scillse . 




giv. 


Tinct. digitalis 


. 


3ij- 


Infus. senegse . 


ad 


3xJ--M 



S. — Take a tablespoonful in water every six hours. 

Guy's or Baly's pill, containing 1 grain each of squill, digitalis, 
and blue mass, is an invaluable remedy where there is no urgency. 

Nitro-glycerin, in small and often repeated doses, as -J minim of 1 
per cent, solution every fifteen minutes for four or six hours, some- 
times starts the kidneys. 



HEART, VALVULAR LESIONS OF. 353 

Where the kidneys fail to respond, the bowels may be made the 
channel for the removal of much fluid. Saline purgatives may be 
used for this purpose. Hay's method of purging by concentrated 
solution of magnesia sulphate (see page 77) may be employed where 
the general anasarca threatens to cause suffocation. Cream of tartar 
may be used to keep up the effect of the purgative. Pulv. jalapse comp. 
is a favorite drug. Puncturing the limbs or tapping the peritoneum 
may be resorted to. Acting upon the skin, as in Bright's disease, by 
hot air and vapor baths and pilocarpine, is not satisfactory. 

Diuretin, which is a sodio-salicylic compound of theobromine, has 
been used with great success in the dropsy caused by valvular disease. 
The dose should be up to one drachm daily — i.e., about 5 grains every 
two or three hours. It sometimes causes very marked increase in the 
urine and rapid disappearance of anasarca. 

Recently lactose has been praised by See as the most powerful of 
all cardiac diuretics ; 3 ounces dissolved in 4 pints of water is made to 
replace all other liquids. Enormous increase in the urine is said to 
follow. It should be stopped after ten days and again commenced. 

The general visceral congestions are to be relieved by the same 
means — i. e., by combinations of various diuretics aud by brisk saline 
cathartics. Dry cupping over the chest and loins may give relief. 

Pulmonary embarrassment may come rapidly, causing sudden and 
dangerous dilatation of the right side of the heart from the congestion 
of the lungs. In such cases life may be prolonged by making a good- 
sized incision into a vein in the arm and removing 10 ounces of blood. 
Leeching may be tried, but where the lividity and orthopnoea are suf- 
ficient to call for venesection, leeching is of doubtful value. Where 
leeching has failed, cupping over the bites may do good. Ether and 
ammonia should be given. 

Bronchial inflammations following congestion should be treated by 
brisk counter-irritants and expectorants while cardiac tonics are 
allowed time to act. The inhalation of oxygen, and compressed-air 
baths, have been recommended to relieve the dyspnoea. 

Sleeplessness may be met by opiates if the bronchial surface is free. 
Chloral is doubly dangerous in cardiac cases with a weakened ven- 
tricle, but -§• to \ grain morphine hypodermically often acts most bene- 
ficially, and relieves dyspnoea and orthopnoea and cardiac asthma. 
Paraldehyde and sulphonal are unobjectionable. 

Syncope or sudden cardiac failure must be promptly met by ether 
and ammonia, hypodermically or by mouth. The hypodermic injec- 
tion of strychnine may be invaluable. Alcoholic stimulants and 
sparteine should be freely given, and brandy or whiskey may be 
injected hypodermically or by the bowel. 

Hypodermic injection of j to 1 ounce of a 6 per cent, salt solution 
causes rapid rise of blood pressure, which lasts for some hours. 

A single induction shock may be tried with advantage. 

Cardiac pain is often a troublesome symptom. It is best met with 



354 HECTIC FEVER. 

local applications. Belladonna plaster over the heart affords surpris- 
ing relief in many cases. This symptom is often associated with pain- 
ful palpitaions. For the relief of the abnormal cardiac action, accom- 
panied by pain, in old valvular cases there is no remedy equal to 
large doses of iodide of potassium. The writer has obtained good 
results from the following combination : 



. — Tinct. digitalis .... 
Potassii iodidi .... 


. 3ijss. 


Ext. erythrox. fid. . 
Spt. setheris nitrosi . 
Aquae et glycerini . 


• • • • lij- 

• • • • I* 

. ad giv. — M. 



S. — Take a teaspoonful in water after meals four times a day. 

Iodide of potassium is a drug of the greatest value for the relief 
of very many of the distressing symptoms of failing compensation. 
Germain See strongly maintains that it is a true cardiac tonic, 
superior to all others in dilating the arterioles, diminishing the periph- 
eral resistance, and enabling the heart to recover its contractile power, 
and, at the same time, greatly promoting its nutrition. Laborde in- 
sists upon the iodide of potassium as being the true medicament of 
the heart. 

Where the palpitation is liable to come on in severe attacks, nitrite 
of amyl or nitro-glycerin (see Angina, page 43) may be used. 

HECTIC FEVER. 

The first indication is to remove, if possible, the cause upon whose 
presence in the system the hectic depends. Any suppurating cavity 
should be freely incised, washed out, and drained. Diseased bone and 
affected joints should be excised, and every source of suppuration dealt 
with upon general surgical principles. 

Empyema, tubercular lesions of the bowel, lung, and kidney, tend 
to wear out the patient through the hectic which they produce, and 
where the cause cannot be removed, the febrile symptoms may be kept 
in check. Sometimes, if the patient can be kept alive for a sufficient 
time, the cause of the hectic may wear itself out, and in such a case 
palliative treatment is of the greatest importance. 

The diet should be most sustaining, being given in the most con- 
centrated form at very short intervals, and, of course, in moderate 
quantities at a time. Alcoholic stimulants may be freely administered, 
and everything that supports the patient's hopes and encourages sleep, 
appetite, and digestion must be carefully attended to. Abundance of 
pure, warm, dry air is of much importance in checking the suppurative 
process. 

The paroxysm of chills, fever, and perspiration can be modified or 
prevented by antipyretics. Under Phthisis the action of these remedies 
and the treatment of night-sweating will be considered. 



HEMIPLEGIA. 355 

In the early part of the paroxysm during the chilly stage, a little 
warm stimulant may be given, and when sweating is profuse, the skin 
may be freely sponged with cold or hot water and vinegar, to which a 
little tincture of belladonna is added. Before the rise of temperature 
is expected, a moderate dose of antipyrine or antifebrin (10 grains of 
the former or 6 of the latter) will effectually prevent the- paroxysm 
altogether, or so modify its intensity as to cause little waste or ex- 
haustion. 

In severe and prolonged cases 30 grains of antipyrine may be given, 
and half this dose, repeated in one hour, if the temperature does not 
fall ; should the fever not yield to the second dose, 15 grains may be 
given in another hour (60 grains in all). 

After a full dose given in this way, a fall from 105° to 97° or 98° 
may be confidently expected, and the fall may last for twenty-four 
hours or more. Sometimes rather alarming prostration follows this 
treatment, but, though the writer has never seen serious symptoms 
follow, he has latterly given up large doses when the fever is high for 
small ones given before the expected rise. Under Phthisis the manage- 
ment of this condition will be more fully considered. 

Quinine is a drug of great value, and it may be given in 5 grain doses, 
and, where it checks fever, it may be continued for any length of time. 

HEMICRANIA— See Megrim. 

HEMIPLEGIA. 

Under the head of Apoplexy the treatment of hemiplegia in its first 
stages has been described. After the patient has recovered in every 
other respect from the seizure which caused his attack, the only 
symptoms remaining may be the loss of power in the muscles of one 
side of the body. 

The treatment at this stage must be directed to his general condition ; 
little can be done for the paralysis. The bowels and bladder must be 
carefully looked after, cathartics or laxatives being necessary in most 
cases. Drugs are of little use in hastening the disintegration and 
absorption of the clot upon which recovery depends, active interference 
being fraught with danger. Strychnine is liable to increase the mischief, 
and its utility at all stages of the affection is somewhat doubtful. 
Bromides with iodides may be tried, and at a later stage phosphorus in 
small doses may be beneficial. The diet should be sustaining but 
unstimulating, and the less animal food and alcoholic stimulants the 
better. A pure vegetarian diet with milk is indicated. Mental repose 
should be maintained. When the patient is able to move about, the 
natural exercise will improve the nutrition of the affected muscles. 
For the first month no attempt should be made to stimulate them, but 
gentle friction cannot do harm. As long as symptoms of cerebral 
irritation exist, massage and electricity are contra-indicated. 

When a couple of months have elapsed, and the only sign of trouble 



356 HERNIA. 

that is evident is weakness in the affected muscles, massage should be 
cautiously commenced and fairly tried, and along with it electricity. 
The current applied to the muscles of the extremities may be con- 
tinuous or faradic, the latter being used only after a few weeks trial of 
a weak continuous current. Different opinions prevail about the 
wisdom and utility of attempting to reach the lesion itself. The writer 
has seen decided benefits follow the application of a current from 5 
Leclanche elements, with one large electrode upon the forehead and 
the other over the occiput. After a week, the current strength may 
be doubled, and he has employed 10 cells, causing the current to flow 
from an electrode placed over the site of the hemorrhage on one side, 
with the other pole situated over the opposite region of the skull. Free 
exercise may be permitted, and every factor likely to cause a return of 
the hemorrhage should be carefully guarded against. 

Horsley has recommended the ligature of the common carotid trunk 
as a prophylactic measure against further hemorrhage in those cases 
where a slight cerebral hemorrhage has already occurred. (See under 
Apoplexy, page 53. 

HEPATITIS— See Liver Diseases. 

HERNIA. 

The treatment of abdominal hernia is -outside the scope of the 
present article. Only a very brief account of the management of a 
few of the many forms commonly met with need be given. Such 
methods will be mentioned as may be useful when the urgency of the 
case prevents the medical attendant consulting any of the text-books 
or standard works on surgery. 

Given a case of recent hernia in a patient hitherto free from any. 
symptoms or signs of the affection, the first duty of the surgeon should 
be to effect its reduction. After its return (when reducible) the pal- 
liative treatment, by means of a suitable truss, is generally deemed all 
that is necessary. 

To effect reduction, in most cases in which no strangulation has 
taken place, it is only necessary to place the patient in the horizontal 
position, when the hernia will generally slip up spontaneously. If 
not, a gentle application of the taxis will secure this end, after which 
a neatly fitting truss, to be worn constantly in the daytime, will keep 
it from descending. 

In infants the constant application of a truss day and night will 
effect a complete cure within a year in the majority of instances of 
inguinal hernia. It will be well, however, to continue the use of the 
truss for another year. In adults, however, the truss must be worn for 
very long periods, and generally for the remainder of life. 

Of the varieties of trusses there is practically no end. Any instru- 
ment which fits comfortably and effectually prevents the descent of 
the bowel, without producing pain or chafing of the skin, and which 



HEKNIA. 357 

does not interfere with the free movements of the body, may be re- 
garded as safe. As a rule, the pad should not be of such a shape as 
will ultimately lead to enlargement of the original opening. This is 
of much importance in the treatment of infantile hernia. The instru- 
ment, in the case of adults, may be removed after retiring to rest, but 
it should be adjusted before the patient resumes the vertical position. 
Where the means and opportunities of the patient permit, it will be 
well to have an instrument specially made and fitted by an experienced 
instrument-maker. The cheap ready-made trusses are often a source 
of much trouble and annoyance. It is advisable for the patient to 
have two instruments. In case of any accident or mishap, the reserve 
truss may be used. Fatal results have often occurred while the patient 
has been going about without support during the period that his truss 
has been under repair. 

The measurement for a truss for inguinal or femoral hernia may be 
made by passing a tape line round the pelvis, less than one inch below 
the iliac crests, the ends meeting at the hernial orifice. 

The utmost cleanliness should be observed, especially in young sub- 
jects, and the skin under the pad may be frequently dusted with French 
chalk or oxide of zinc. A very common mistake is made in forgetting 
that, owing to the rapid growth of the body in very young subjects, the 
truss soon becomes too small. 

The writer has observed almost complete arrest of development of 
the testicles from the continuous use of tight-fitting trusses — a result 
which he does not remember to have seen noticed by surgical writers. 

Irreducible hernia will require considerable modifications in the 
shape, form, size, and consistency of the pad suitable to the require- 
ments of different cases. A bag-truss will be necessary for large 
tumors, while small ones may be treated by a small hollow pad. 

Umbilical hernia must be retained in position by a suitable concave 
circular pad. As these hernia? are very often irreducible, the best 
method for their treatment will consist in the adjustment of a neatly- 
fitting abdominal belt, constructed so as to protect and support the 
prolapsed intestine. In the case of the very common infantile form, 
a flattish, firm, leather pin-cushion of circular form, without much 
convexity, and many times larger than the opening, should be placed 
inside the roller, and kept firmly bandaged over the umbilicus. The 
insertion of convex, button-shaped pads are to be condemned, as they 
tend to keep the aperture from contracting. Often a few strips of 
strapping passed across the opening are sufficient to keep it closed. 

When a hernia showing signs of strangulation comes before the 
surgeon, prompt measures must be immediately undertaken for its 
relief. It may be down but a few hours when dangerous constriction 
may have already set in. Recent hernia? of any variety, and femoral 
hernia especially, are very .dangerous. Old hernia? are not so rapidly 
fatal, but under no circumstances is time to be lost in dealing with a 
strangulated hernia. 



358 HERNIA. 

The bowel must be returned within the abdomen by the taxis, or, 
falling this, by the operation of herniotomy. 

The taxis, with the gentlest pressure, will often be found to speedily 
reduce the hernia if found soon after its descent, but when symptoms 
of strangulation have set in for any length of time the taxis is too 
often a failure. It should be tried in all recent cases, but the utmost 
gentleness should be maintained. When a hernia has been discovered 
in a patient suffering from strangulation for several days, the first 
touch of the surgeon's fingers upon the tumor will convince him that 
manipulation means further injury of the patient's chances of recovery. 
Pages might be written upon the dangers of the taxis. Most surgeons 
are loud in their condemnation of it, and some go so far as to say it 
should not be attempted except under chloroform, and then only for a 
few seconds. No rule or rules can be laid down to guide the student 
in the correct appreciation of how far he is justified in perservering in 
his attempts to force the knuckle of bowel or omentum back into the 
abdomen. The conscientious attendant must be left to his own judg- 
ment of how far he is justified in persisting in manipulation before 
seeking the aid of an experienced surgeon. 

Unfortunately an unworthy motive may creep in at this time, and 
though it is not a pleasant duty to dwell upon the petty weaknesses of 
our nature, nevertheless it is right that the young practitioner- should 
be placed upon his guard against himself. 

He may feel that in calling in a surgeon who might probably reduce 
the tumor at once he may lose the confidence of his patient and of 
those around him. This sometimes tempts him to prolong his efforts 
at the taxis until serious damage is done to the contents of the sac. 

It is much better to take the patient into his confidence, explain the 
exact situation and its dangers, and seek the aid of an expert without 
loss of time. In hospital cases it has been often the experience of the 
writer to find that the taxis has had an exhaustive trial at the hands 
of several industrious performers before admission. In such cases it is 
sometimes wonderful to see how little injury has been inflicted upon 
the bowel, and one is at times forced to conclude that too much has 
been made out of the dangers of prolonged trial of the taxis, though 
doubtless the nutrition and circulation of the constricted parts in these 
instances may have been seriously interfered with. 

To apply the taxis the patient should be placed upon his back, with 
his shoulders raised and the thigh partially flexed and rotated inwards , 
so as to cause as much relaxation as possible of the tissues in the 
neighborhood of the neck of the sac. 

The surgeon lightly grasps the neck of the sac between his left thumb 
and forefinger, and when all is steadied, with all the fingers and the 
thumb of the right hand he seizes tho tumor, and attempts, by a com- 
bination of a pulling down movement and squeezing, to expel the 
liquid and gaseous contents of the sac, and secure its return. It is 
advisable, as just said, to make traction downward at first before an 



HERNIA. 359 

attempt is commenced at pushing up the tumor. The pressure should 
be very moderate and even, and accompanied with a slight kneading 
movement. The degree of force applied (always slight) should be 
exceedingly gentle in cases where tbe hernia has been long prolapsed. 
Where the symptoms are very acute from the moment that the hernia 
has descended, or where there is evidence that the sac is inflamed or 
that the gut is gangrenous, the taxis should not be attempted. 

After gentle pressure for some time the operator may have the satis- 
faction of feeling the hernia suddenly slip up with a jerk and gurgle. 
If he has used no force he may feel confident that all is well, but if 
considerable pressure was being employed at the moment of the ascent 
of the tumor he may reasonably fear that the hernia has been returned 
en masse, or that rupture has occurred. Omentum goes up gradually 
and without noise. 

When the taxis fails after a moderate trial, the patient may be put to 
bed, and before deciding upon herniotomy the effect of cold upon the 
tumor may be tried. Where the strangulation is very acute, or where the 
bowel has been prolapsed for days, or where there is evidence of gangrene 
or inflammation, or where the hernia is known to have been irreducible 
before the symptoms of strangulation set in, no further delay should be 
permitted, but herniotomy should be at once resorted to. In recent 
cases, however, there is a reasonable hope that cold combined with the 
taxis may succeed where the latter has failed alone. 

Ice may be applied to the tumor for three or four hours. Leiter's 
tubes may be tried, or the intense cold produced by the ether spray 
apparatus may be utilized. These in recent cases have been known to 
effect reduction. They are valuable when the symptoms are not urgent 
and where vomiting is not severe ; and in cases of delay in procuring 
an operator they are of great value if they only succeed in preventing 
continuous attempts at the taxis. A large dose of opium (2 to 3 
grains) or a hypodermic of morphine may be given under such circum- 
stances with advantage. 

Hot baths are doubtless of much value where a large bath can be 
brought alongside the patient's bed, but the usual practice of causing a 
patient who is suffering from strangulated hernia to walk down one or 
more flights of stairs to the bath-room is a serious danger. 

The taxis with the body inverted, or the intestines inflated by ene- 
mata, and various other plans of this kind, should be discountenanced. 

The practice of aspirating the contents of recent hernise and then 
applying the taxis has found favor with several surgeons, and if a very 
fine hollow needle be used, there is little danger of extravasation. 
Thus, Hearn has tapped the tumor with a hypodermic needle in thirty- 
two cases, with easy reduction in twenty-eight. In the remaining cases, 
after the tapping, the hernia was operated upon, and no traces of the 
punctures could be detected. It fulfils all he claims for it — viz., it 
avoids the delay almost inseparable from herniotomy, it lessens the 
evils of the taxis by diminishing the tension of the tumor, and it very 



360 HEENIA. 

often does away with the necessity of the cutting operation, with its 
septic dangers. 

Where the above-mentioned measures fail, the last final trial of the 
taxis is to be made under the influence of chloroform or ether. Before 
administering the anaesthetic, it should be finally decided that if the 
tumor cannot be reduced under a few minutes' trial the surgeon should 
proceed with the operation of cutting down and relieving the stric- 
tured bowel without waiting for the patient to come from under the 
influence of the drug. Often reduction takes place easily under chlo- 
roform where the taxis has previously failed without its aid. 

It sometimes becomes a serious question whether the surgeon is 
justified in operating, owing to the advanced state of collapse in cases 
where there has been great delay before coming under notice. The 
death of the patient being obviously inevitable without relief, he 
should always get the benefit of the doubt, and the operation should be 
always tried. It is surprising how the most unpromising cases some- 
times recover. The writer has operated successfully in a case where a 
recent hernia had been down seven days. 

The operation is not necessarily a very painful one, and where chlor- 
oform is not admissible, cocaine injected over the tumor considerably 
relieves pain. 

The writer has assisted Dr. J. W. Browne at a case where the pa- 
tient, owing to a heart complication, decided to have herniotomy per- 
formed without an anaesthetic. She watched some of the stages of the 
operation with manifest interest, and exhibited little signs of uneasi- 
ness, though cocaine was not used. 

The hair should be shaved from the surface of the tumor and the 
skin carefully washed with sublimate or carbolic solution. As the 
patient lies upon his back with the shoulders raised and the knees 
flexed, an incision should be made over the neck of the sac. Its ex- 
tent will depend somewhat upon the size of the tumor. In femoral 
hernia it may be made in a vertical direction, internal to the crual 
opening, or in an oblique direction, somewhat parallel to Poupart's 
ligament. In inguinal hernia the incision may be best made in the 
direction of the canal. 

The tissues are to be carefully divided, each layer being incised 
separately until the sac is exposed. The free use of the director is an 
advantage, as the appearance and thickness of the different layers of 
tissue vary so widely in almost every case. Vessels should be tied as 
the operation proceeds. After exposure of the sac, the tissues outside 
its neck, if seen, and felt by the index-finger to be the cause of the 
stricture, are to be carefully divided upon a hernia director by means 
of a suitable hernia knife, the surgeon watching the coil of bowel 
which may bulge in front of his knife, and seeing that it is not in- 
jured. A short incision upward is the best, and if easy and satisfac- 
tory reduction follows with the characteristic jerk, the sac need not be 
opened. Where any doubt exists about the thoroughness of the re- 



HEKNIA. 361 

duction or about the state of the bowel, and especially in cases where 
the gut has been long strangulated, the sac should be opened upon a 
director by pinching up a fold with the forceps. 

In these latter cases it will be better practice to open the sac first 
without waiting to relieve the stricture, as the parts can then be thor- 
oughly examined in situ. If found satisfactory, the strictured neck of 
the sac may then be divided and the contents returned. 

The condition of the bowel is a serious consideration ; if found pur- 
ple or almost black, but free from gangrene, though covered with 
lymph and ecchymosed, it may be safely returned. 

In other words, if alive and unperforated or unruptured, it should 
be returned. When found to feel like wetted leather and devoid of 
its natural elasticity, and ashy in color or fetid in smell, the surgeon 
knows that it is dead. If ruptured or perforated it is equally unfit 
for return. The best course, then, is to thoroughly define the exact 
extent of the mischief and resect the destroyed part. Small perfora- 
tions may be treated by removing an oblong portion of the intestinal 
walls and suturing deeply and superficially, after which the knuckle 
or coil of bowel may be returned. 

The less handling of the sac contents the better, and the operation 
should be carried out under antiseptic precautions. 

Omentum, unless when gangrenous, should be returned. Some- 
times, however, its reduction is impossible, in which case it may be 
excised, and after ligature of all vessels, the stump may be returned. 

On reduction of the hernia, Treves, after closing its abdominal 
oriftce, recommends the excision of the sac. Generally, it will be 
found convenient to free the neck of the sac, after which a catgut 
ligature may be employed to thoroughly close the peritoneal cavity, a 
portion of the ligatured sac below the catgut only being excised. 
This hastens the healing of the original wound which may be sutured, 
and a drainage-tube left in situ, and a large pad of iodoform gauze, 
with a firm hernia spica bandage applied. 

Ice and opium, minute quantities of liquid nourishment and abso- 
lute rest, comprise the chief points in the after-treatment. The bowels 
should not be allowed to act for ten days, and then only by tepid 
water and olive oil. 

Inflamed hernia : The cause should be remedied, the irritation of a 
truss often being the factor, in a hernia which is not reducible. The 
taxis may be the cause, hence any attempt to reduce a hernia, the 
seat of inflammation, should be avoided. Rest in bed, with the appli- 
cation of cold to the tumor, is generally all that is required. The 
best method is to apply Leiter's tubes over the hernia or to use an ice 
bag. Pain should be relieved by opium which is also necessary to 
secure absolute rest to the bowel. The diet should restricted to beef 
tea or iced-miik. 

The radical cure of hernia has been carried out of late years with 
wonderful success, Wood having operated without a single death upon 

24 



362 HERPES. 

200 consecutive cases of simple reducible hernia in which truss-pres- 
sure had failed to effect a cure. 

Irreducible hernia} and strangulated hernia, after herniotomy, have 
been also successfully dealt with in this way. Dr. H. O'Neill has had 
a series of successful cases in young children. 

The rationale of the treatment consists in closing up and obliter- 
ating the internal ring and sides of the. inguinal canal, with the pillars 
of the external ring, the neck and sac cavity. This is carried out by 
means of one silvered wire ligature applied subcutaneously. 

The operation is modified in endless ways by different surgeons. 
Some, like Banks, remove the entire sac. Macewan, after separating 
it, leaves it as a support for the weakened abdominal walls. Spanton 
causes closure of the canal by a corkscrew instrument left in situ after 
being inserted over the finger when the tissues are invaginated. Many 
of the modifications are unnecessar}^ complications. 

For the details of the operation and its modifications, the reader is 
referred to the exhaustive article on the subject by Professor Wood 
in Heath's Dictionary of Practical Surgery, or to Fowler's article in 
the November number of the Brooklyn Medical Journal, 1889. 

HERPES. 

For the most part, herpes prasputialis, herpes labialis, and herpes iris 
are trivial and short-lived troubles, which require no treatment. Occa- 
sionally a mild local sedative may be applied, and, owing to the common 
site of these eruptions — viz., on the face, lips, or hands — powdery 
preparations are inconvenient. An ointment like the following 
answers all cases : 

R. — Calamin. praep 3j. 

Liq. plumbi subacetat. . . . . . . £ss. 

Unguent, zinci oxid ^ jss. — M. 

The vesicles may be painted over with flexile collodion where an 
ointment is not convenient. 

In some cases of herpes prseputialis, with a long foreskin, powders 
are especially useful. 

Herpes zoster, or shingles, is sometimes a very painful affection. 
Mild cases require little treatment, except local applications, to 
prevent injury and friction to the vesicles until they spontaneously 
wither up. 

A piece of lint or soft linen, smeared over with the above ointment, 
laid upon the seat of the eruption and covered with a pad of soft, 
absorbent wool, fastened with a light bandage, is a simple routine 
plan, meeting all the requirements in most cases. Where pain is 
severe, cocaine may be added to the ointment, or cocaine or morphine 
can be mixed with collodion and painted over the vesicles. Where the 
situation of the eruption permits, powders are better. The parts may 



HICCOUGH. 363 

be well dusted with powdered starch, oxide of zinc, calamine, bismuth, 
calomel, lycopodium, Fuller's earth, talc, etc. 

Acute neuralgic pain may demand anodynes by the mouth or, 
morphine hvpodermically, and should the vesicles burst or get rubbed, 
the smarting may be relieved by lotions containing lead and opium. 
Many writers testify to the remarkable power exercised by small and 
frequent doses of (y 1 ^ grain) phosphide of zinc in diminishing pain and 
cutting short the eruption. With the view of aborting the attack, 
Unna paints the affected region over with a paste made by rubbing 
ichthyol with water, or by applying a gelatin paste containing zinc 
and resorcin. The continuous or interrupted current has been used with 
the same intention, the electrodes being placed over the course of the 
affected nerve. 

Dupas has reported that the eruption may be caused to abort in a 
few hours if the following treatment be at once commenced. He soaks 
absorbent wool in 90 per cent, alcohol, lays it upon the seat of the 
developing eruption, and covers it with oiled silk. A 2 per cent, 
alcoholic solution of resorcin, or of tannin, or of menthol, or thymol, 
acts even more rapidly. Thiol, in 30 per cent, aqueous solution, has 
also been found very efficacious. 

The neuralgia sometimes following the attack may be treated with 
quinine, salicylates, antipyrine, arsenic, etc. The writer has seen 
colchicum prove useful, as recommended by Fagge. He has had good 
results from the continuous current. 

"Where the eruption appears in the course of the ophthalmic division 
of the fifth nerve, the severe pain must be relieved by narcotics or 
antipyrine. Cocaine may be dropped in solution into the eye, and the 
lids covered with a piece of lint smeared with an ointment of calomel 
(15 grains to 1 ounce), and the eye bandaged over with a large pad of 
borated wool. The greatest care must be exercised in preventing the 
accompanying conjunctivitis and keratitis from causing ulceration and 
perforation. 

HICCOUGH. 

The cause, when possible, should be removed, and as this may often 
be found in the stomach, a smart emetic may stop this troublesome 
symptom. A teaspoonful of mustard in a tumblerful of warm water is 
a speedy and efficient agent for producing vomiting. 

Sedatives to the gastric surface, as morphine, cocaine, and chloral, 
may be tried; they often fail. Morphine hypodermically or chloro- 
form inhalation will sometimes remove the hiccough entirely. Xearly 
always temporary relief can be procured from their use. Doses of 
narcotics sufficient to affect the respiratory centre may relieve speedily ; 
if not, their administration should be stopped, as they make matters 
worse. 

Cannabis indica, opium, hyoscyamine, camphor, oil of amber, mag- 
nesia, musk, vinegar, bromide of potassium, bismuth, antipyrine or 



364 HIP-JOINT DISEASE. 

antifebrin, belladonna, ether, nitroglycerin, hot brandy, nitrite of amy], 
iodoform, creasote capsules, turpentine, hydrocyanic acid, strychnine, 
valerianate of zinc, pilocarpine (hypodermically), ice, and many other 
remedies have been used successfully. Unfortunately, the use of any 
remedy is purely empiric. What relieves or cures at one time will 
often fail utterly upon the next trial. A smart purge should be given 
when the symptom has continued for any time, and the various drugs 
in the above list may be tried in turn. 

Many methods have been advocated by which the nerve-supply of 
the diaphragm may be influenced, either directly, reflexly, or by 
inhibition. Thus a sudden fright stops hiccough in children promptly, 
but though the writer has often proved this, there are serious objec- 
tions to the use of this agent as a therapeutic remedy. 

A less objectionable method of treating the affection is by directing 
the patient to take a deep inspiration or expiration, and to hold his 
breath as long as he possibly can. Raising the arms above the head, 
and keeping them there until the muscles tire, sometimes stops it. 
Counter-irritation to the stomach, cervical spines, or over the phrenic 
nerve may succeed. Pressure over the nerve in the region of the 
scalenus anticus sometimes stops it instantly. Sneezing may be in- 
duced by snuff or ammonia, and may cause the hiccough to cease. 

Cold applied to the lobe of the ear or to the external meatus has 
been found successful, and cocaine may act in a similar way. 

Galvanism seldom does any good, but a smart shock sometimes 
speedily relieves, probably by its moral effect. A cold shower bath 
may act in the same way. These latter agents are especially valuable 
in hysterical cases. 

HIP-JOINT DISEASE. 

The chief indication at the beginning of this serious ailment is to 
prevent all inter-articular pressure. The patient should be put to 
bed upon a hard, unyielding hair mattress with his head comfortably 
raised, but with the shoulders in the same plane as the body. He should 
lie upon his back, and extension by means of the weight and pulley 
should be brought to bear upon the affected limb. This is easily done 
by attaching a loop or stirrup to the ankle and heel by means of 
plaster, to the stirrup a cord is attached which passes over a pulley, 
and to its end a weight of two to six pounds is attached. This treat- 
ment is to be kept up until all deformity disappears, and until pain 
and tenderness about the joint are no longer felt. It is the best of all 
methods of dealing with acute cases, or with those examples of the 
disease associated with much pain or spasm of the muscles. Where 
considerable deformity has already occurred without ankylosis, and it 
is highly desirable that this should not occur in a position which might 
seriously interfere with the use of the limb, the deformity should be 
removed before beginning extension. 

With this object in view the patient should be chloroformed and 



HIP-JOINT DISEASE. 365 

the deformity partially remedied. The utmost caution and gentleness 
being essential in order to avoid setting up further mischief in the joint, 
it is wiser not to insist upon the deformity being entirely remedied 
by manipulation. The extension by pulley and weight will complete 
what force has already partly accomplished under chloroform. 

Unless the deformity be long established or severe, chloroform and 
manipulation will not be required. The weight and pulley, if skil- 
fully adapted, will reduce most angular positions in a few weeks, and 
it will be wise to give extension a trial before resorting to what may 
end in exciting further mischief in the joint. 

Marsh lays stress upon the importance of applying the extending 
force in the direction of the axis of the deformity, otherwise inter- 
articular pressure is not diminished. 

Abduction is best corrected by applying the weight and pulley to 
the affected side as just described. After a few days a long splint 
may be adjusted to the sound limb. This is, moreover, advisable in 
all cases, as it prevents the patient moving or sitting up. 

Where marked adduction is present the deformity must be corrected. 
This is done by treating the affected limb with weight and pulley in 
the ordinary way. The sound limb is then bandaged to a long splint, 
from the inferior end of which a cord is led along the outside of the 
splint to a pulley fastened at the top of the bedstead by fixing a weight 
to the free end of the cord. The extending forces are applied to the 
different limbs in opposite directions, and adduction is minimized. 

As soon as possible the patient should be put into a Thomas's splint 
with a high-heeled boot on the sound foot, and allowed into the open 
air upon crutches. If the affection is at a standstill during the winter, 
bed is the best place for him, and the extension by weight and pulley 
may be kept up for a long period ; but in summer Thomas's splint 
may be applied at an earlier period. It is of vital importance that 
time be not lost in these cases when the season admits of the patient 
getting out. Struma or tubercle is the cause of hip-joint disease in the 
great majority of cases, and the appropriate treatment for this malady 
must be carefully carried out simultaneously w T ith mechanical manage- 
ment. The advantages of change of air and scene and a sojourn at a 
sheltered seaside spot, protected from the north and east, cannot be 
exaggerated, but the temperature should be equable, and the air as far 
as possible free from excessive moisture. All means to improve nutri- 
tion and raise the standard of health should be attended to, but as 
these are referred to under Scrofula they need not be here enumerated. 

The splint should be worn both day and night as long as there are 
any symptoms of mischief. Should pain or tenderness supervene, the 
splint must be removed and the patient placed upon his hard mattress 
with the pulley and weight, and kept there for a month after the acute 
symptoms have passed away. As Thomas's splint must be worn for a 
long period — perhaps two years — steps should be taken to counteract 
the evil consequences which are bound to follow its constant application. 



366 HIP-JOINT DISEASE. 

This can only be done, after local symptoms have disappeared, by the 
careful and judicious employment of gentle massage applied to the 
wasted and weakened muscles of the limb. 

Notwithstanding the most rigorous application of rest, sometimes the 
case goes on to suppuration and enormous abscesses may burrow in 
various directions and set up fatal exhaustion and hectic. 

Aspiration in such cases is a serious mistake. A free deep incision 
to thoroughly evacuate the abscess sac, after which a good sized drain- 
age-tube should be inserted and left till the suppuration process ceases, 
will be the best practice. Where diseased bone is evident* a modified 
excision operation may be confidently undertaken, and all dead bone 
removed and every trace of diseased tissue taken under the strictest 
antiseptic precautions. Barker fills the cavity with iodoform emulsion, 
and puts the patient at once on a double Thomas's splint. 

There is still much difference of opinion regarding the propriety 
of resorting to the ordinary operation of excision of the hip. The 
writer, speaking from a limited experience and more from the stand- 
point of a physician, might summarize' the objections in a sentence. 
In advanced cases the results are bad, in early cases they are often satis- 
factory, but to ensure these satisfactory results the operation, which is 
always a serious one, must be undertaken at a stage in which there 
would be still legitimate ground for expecting a better result from 
extension and rest. 

The recognition of the tubercular nature of hip-joint disease of late 
years has led to more persistent advocacy of operative interference, 
and the various methods of treating local tubercular abscesses is fully 
described under Tuberculosis. The Dublin method of drilling the bone 
in the neighborhood of the joint, washing out with carbolic lotion and 
securing absolute fixation has given excellent results. 

Where there is extensive disease of the head and upper end of the 
shaft of the femur with a similar condition of matters in the pelvic 
bone, the only course open is amputation. A case must be indeed very 
far advanced which justifies the surgeon in refusing to amputate. The 
aspect of the parts which at first sight is so unpromising may be the 
best reason to hope for a success in apparently hopeless cases. The 
pale gelatinous and strumous infiltration of all the tissues, riddled 
with sinuses, may be divided in some cases with surprisingly little 
hemorrhage and shock to the system. In 1872, the writer, with Dr. 
Newett, operated in an apparently hopeless case. The femur was found 
extensively diseased in its upper third, and was the seat of spontaneous 
fracture, and there was advanced destruction of the ilium, ischium, 
and acetabulum. After all dead bone had been removed and a con- 
siderable portion of the pelvis gouged away, the vessels were dis- 
covered to be so diseased as not to bear a ligature, and it was found 
necessary to dissect up the femoral artery in the flap, and apply a liga- 
ture to the external iliac in the abdomen, which the writer accordingly 
did. 



HOAKSENESS — HYDATIDS. 367 

Though the patient had suffered much from night-sweats and 
haemoptysis, she made an excellent recovery, and is still living and in 
robust health. If the reader wishes to see the best statement upon the 
results of treatment of hip-joint disease without excision, he should 
consult Professor Marsh's valuable paper in the Lancet of July, 1889, 
in which he shows that though the early operation is followed by rapid 
healing, the limb is weak and defective in usefulness when contrasted 
with the serviceable member the result of rest and extension 

HIVES— See Erythema. 

HOARSENESS. 

The removal of the cause should be the first object, simple over- 
straining of the voice being a common cause of this condition, rest 
should, as far as possible, be insisted upon. The use of the following 
gargle relieves, and when some effort of the voice is inevitable, either 
in singers or public speakers, it may tide them over an engagement : 

R. — Acidi tarmici ^j. 

Pulv. sodii bor. gj. 

Tinct capsici . . . . '. . . ^ss. 

Aquse rosse 3 x. — M. 

Make a gargle. 
S.— To be used frequently. 

Where hoarseness results from or is symptomatic of a true inflam- 
mation of the larynx, the remedies suitable in laryngitis are to be used. 
Local laryngeal troubles, as small tumors or thickening of the cords, 
interfering with the closure of the rima may be dealt with surgically. 
Syphilitic affection will probably disappear under mercurials. Exuda- 
tion, as in diphtheria, may only betray itself in hoarseness, and demands 
treatment of a prompt and serious character. (See Diphtheria.) 
Hoarseness, depending upon centric nerve lesions or the pressure of 
aneurismal growths causing partial paralysis of the adductors of one 
cord, will demand attention to the primary lesion. 

(See also under the heading of Laryngitis for the treatment of the 
various conditions of which hoarseness is the chief symptom. See also 
under Throat.) 

HOSPITAL GANGRENE— See Gangrene, p. 272. 

HYDATIDS. 

In the consideration of the treatment of this serious malady, the 
question of prevention should hold the first place. The disease is the 
direct result of the introduction into the human alimentary canal of the 
eggs of the tcenia echinococeus — a small tapeworm infesting the dog 
and wolf. The human hydatid is the larval form of this parasite. 



368 HYDATIDS. 

The eggs find their way into the human stomach chiefly through drink- 
ing-water. Hence the necessity, in districts where the parasite 
abounds, to look more closely to the filtration of water and the purity 
of food. The utmost scrupulosity should be observed as regards the 
personal cleanliness of all who come into close relations with dogs. 
This minute worm is often found in dogs in this country in vast num- 
bers in the small intestines. As the mature worm does not exceed 
one-sixth of an inch, it is easily seen how readily the invisible eggs or 
the last small joint of the worm which alone contains the developed 
sexual organs, may find entrance into the human stomach in water or 
on salads, etc. 

Curative treatment must be surgical. The wild statement made about 
the efficacy of kamala, turpentine, iodides, chloride of sodium, etc., have 
been proved to be devoid of truth. No drug at present known can be 
expected to destroy the hydatid when given by the mouth. 

About surgical procedures there is much diversity of opinion. Elec- 
trolysis has had its advocates, and Fagge and Durham have reported 
ten consecutive successes after passing- two fine gilt needles into the 
cyst at different places. The positive pole of a ten -cell battery was 
connected with a sponge electrode placed over the tumor, while the 
needles were attached to the negative pole ; ten minutes sufficed for 
the passage of the current. Fagge attributed the success of the opera- 
tion to the punctures made by the needles, permitting some of the fluid 
to escape out of the cyst into the abdominal cavity. He tried simple 
acupuncture, and found it did equally well. Suppuration never 
occurred. 

One fact has been abundantly proved, that if a minute quantity of 
the liquid contents of the cyst be drawn off with a fine syphon -trockar, 
the result may be the death of the parasite and the gradual shrinking 
or withering up of the tumor. This is by far the best treatment for 
cysts situated in solid organs like the liver. Aspirating these cysts, 
when embedded in any solid region, is apt to cause such traction upon 
their walls by suction as may lead to inflammation and suppuration. 
If the aspirator be used, all the contents should not be removed. 
Where a small cyst depends from the liver into the abdominal cavity, 
the removal of a portion or of the whole of the fluid contents by a long, 
very fine aspirator needle attached to Dieulafoy's instrument is the 
best practice. The operator should be slow to repeat the tapping in 
case the cyst should soon fill again, until a sufficient time has elapsed to. 
show whether the hydatid still lives. In such cases it is very unde- 
sirable to run any risk of suppuration, and time may prove that the 
operation has fulfilled its object, and further waiting may show the 
gradual withering of the tumor. 

Where a movable cyst of moderate or large size hangs very freely 
into the abdomen, it is considered safer practice to establish adhesions 
between the walls of the abdomen and cyst before tapping. This can 
be done in any of the ways in which ovarian cysts were formerly 



HYDATIDS. 369 

treated. Should the hydatid, however, be freely movable, the method 
of inserting a number of hare-lip pins through the abdominal wall into 
the oyst, and leaving them there for twelve hours, may be employed. 
Afrer the withdrawal of the pins, the cyst, if a small one, may be tapped 
with a fine needle, and if of large dimensions a wide trochar may be 
plunged into it, and the cavity washed out daily with antiseptic solu- 
tions to get rid of the daughter cysts in its interior. 

Fitzgerald has successfully removed very large hydatids by per- 
forming abdominal section, and in this direction surgical progress is 
rapidly marching. 

Morris, after removing the fluid contents, incises the cyst-walls and 
stitches their divided edges to the edges of the incision in the abdom- 
inal parieties, without taking any means for insuring previous adhesion 
between the cyst-wall and abdominal wall before operating. 

Gardner, of Australasia, has successfully operated very frequently 
for hydatids, and he states that he has no hesitation in resecting ribs, 
opening the pleural cavity, incising the diaphragm, stitching the cyst 
to the diaphragm, and the diaphragm to the costal pleura and skin in 
all cases in which he finds cysts situated on the convex surface of the 
liver, a drainage-tube being always inserted into the lowest part of the 
pleural cavity to provide drainage of any subsequent empyema. 

Where suppuration has already occurred, the hydatid cyst may be 
treated as an ordinary abscess, and dealt with by free incision, by 
washing out with antiseptics, and by establishing drainage. 

The injection of various substances into the cyst, in ordinary cases, 
with the view of causing the death of the hydatid has been advocated, 
and is still sometimes practised, but it is unnecessary, and liable to be 
followed by profuse suppuration. When the cyst is adherent and a 
large opening made, iodine and other antiseptics may be employed to 
destroy smaller internal cysts too large to come through the opening, 
which should be kept patent by the insertion of a large India-rubber 
tube. 

Ox-gall, extract of male fern, and other anthelmintics should be 
abandoned, their injection into the tumor being certain to cause sup- 
puration, which the surgeon is anxious to avoid. 

Hydatids in the lung or pleura can be successfully treated in any of 
the ways described, the introduction of a long fine needle or trochar 
attached to the aspirator being the best. The guiding principle is that 
obtained by experience — that if even a small quantity of the fluid is 
withdrawn, the cyst may wither up without suppuration. Should sup- 
puration occur in the pleural cavity, a free incision must be made 
between the ribs, and the space washed out and drained as in empyema. 
Abscess of the lung, if near the surface at the base, may in some cases 
he successfully treated in a similar way. Aspiration and subsequent 
injection of carbolic or w T eak bichloride solution have given good results. 
Gardner has performed thoracic section in nineteen cases of lung hy- 



370 HYDKOCELE. 

datid, with only two deaths, and abdominal section in forty-seven liver 
cases, with five deaths. 

Trephining for brain hydatids has been successfully performed. 

HYDROCELE. 

Chronic hydrocele of the tunica vaginalis is a very common affection, 
and one very frequently presented to the surgeon for treatment. If 
the collection of fluid is small and has remained stationary for any 
considerable period, it may be well to let it alone. ,When it has 
already reached dimensions entailing inconvenience or pain, it should 
be tapped. This is done with a moderately fine, sharp trocar and 
canula. The writer uses the largest-sized instrument, generally sup- 
plied with the aspirator. Having placed the patient standing with his 
back against the wall of the room, the surgeon ascertains the exact 
position of the testicle in the tumor, after which he grasps the neck of 
the scrotum firmly between the thumb and fingers of the left hand and 
applies pressure, so as to render the hydrocele very tense. The oiled 
trocar and canula should be held firmly in the right hand, with the 
tip of the index-finger about two-thirds of an inch from its extremity, 
and plunged into the sac, avoiding the testicle. As the trocar is 
withdrawn, the canula is thrust home in the direction of the cord by 
depressing the hand. After the sac of the tunica vaginalis is thor- 
oughly drained, the minute opening closes almost completely ; if not, 
a strip of plaster applied over a bit of lint or gauze is all that is 
needed. Hospital patients generally immediately afterward resume 
work, though this is to be forbidden. In their case it is better to tap 
the tumor after their day's work is over. In a small percentage of 
cases the hydrocele does not again form, but generally the fluid re- 
accumulates at a shorter interval after each tapping. 

Many persons prefer to be relieved in this way when the fluid con- 
tinues to accumulate slowly, but, especially in young subjects, the 
surgeon should recommend a radical operation. This is carried out 
after tapping, by injecting through the canula into the sac, with a 
syringe possessing a long nozzle, one drachm of tincture of iodine and 
one drachm of alcohol. After its injection, the scrotum may be 
kneaded between the finger and thumb, with the view of setting up 
further irritation by the manipulation. 

Different operators have their favorite injections ; some even prefer 
to draw off the injection through the canula before withdrawing it. 
The tincture of iodine may be diluted with a larger quantity of alcohol. 
A good solution is the following (the whole may be injected) : 

R . — Iocli purif. . . gr. x. 

Potassii iodidi . gr. viij. 

Aquae destil . £ iv. — M. 

Care should be exercised in the injecting or drawing off of the liquid 



HYDROCELE. 371 

(when this is done) to prevent the escape of any into the cellular tissue 
outside the sac. 

Tincture of iron, port wine, chloride of zinc, bichloride of mercury 
solution, or a few grains of red precipitate or iodoform, and many 
other irritasing substances, are used, but the above answer most pur- 
poses. It is necessary that every drop of the hydrocele fluid should be 
first evacuated and that the manipulation should afterward insure that 
the injection be made to come into contact with every part of the sac. 
The patient should be sent to bed for a day or two, as sometimes the 
inflammation excited by the irritant sets up considerable local pain 
and uneasiness, though in some successful cases neither pain nor uneasi- 
ness may be experienced throughout. 

Excellent results have been recently obtained by injecting from 5 
to 10 grains of pure carbolic acid, and some surgeons permit the 
patient to immediately resume his work after the injection. It causes 
little pain. 

In one case in which the writer used the carbolic acid injection the 
sac became suddenly tympanitic, but there was no other untoward 
result, and the cure was complete, without pain or distress of any kind. 
It was not possible to see how air had been admitted. The hydrocele 
was an old one, and had frequently been tapped before. 

If a weak solution of cocaine be injected before the irritant, a prac- 
tically painless operation may be performed after its removal. 

In some cases failure results ; the fluid which is secreted after the 
injection does not become absorbed, and the case returns to its old con- 
dition. A second or third trial may be made by injections, each time 
using a stronger solution, and if these fail, the following means should 
be employed. 

Incision of the tunica vaginalis is made for about two inches by 
cutting with a sharp scalpel vertically into the front of the tumor. 
After tying all vessels and washing out the cavity with antiseptics, a 
drainage-tube is to be left m and the edges of the incised tunica are to 
be sutured to the margins of the skin wound, and the scrotum dressed 
antiseptically. 

Partial or complete resection of the tunica vaginalis may be re- 
quired in very obstinate cases, so as to prevent two serous surfaces 
coming in contact. Southam successfully removes the whole of the 
parietal layer. 

Hydrocele in infants or young children may be treated by acupunc- 
ture when iodine applications or cooling or astringent lotions fail to 
cause absorption of the fluid in the closed sac of the tunica vaginalis. 

A glover's needle or hare-lip pin is thrust into the sac through the 
skin over the hydrocele, and without withdrawing it through the skin 
wound it is several times withdrawn from the sac and pushed in again 
in different places. In this way the fluid from the hydrocele passes 
into the cellular tissue of the scrotum and is absorbed, and the case 



372 HYDROCEPHALUS, CHRONIC. 

often ends in a radical cure. Where this measure fails, tapping and 
injections must be resorted to. 

Acupuncture may be used with success in those cases where the 
hydrocele in infants extends for a variable degree along the front of 
the cord without any communication with the interior of the peritoneal 
cavity. It should always be resorted to before injecting with iodine or 
carbolic acid. 

Congenital hydrocele requires different management from the 
varieties just mentioned. In it there is an uninterrupted water-way 
between the cavity of the peritoneum and the tunica vaginalis. Here 
the first object should be to prevent the descent of a hernia through 
the patent canal, and at the same time to take steps to hasten the 
closure of the congenital opening. Both these objects are attained by 
gradually forcing all the fluid back into the peritoneal cavity, and 
applying an accurately fittiug truss to be worn day and night until 
sealing up of the opening is effected. Afterward any accumulation of 
fluid still in the tunica may be treated by acupuncture or injection. 
Where these means fail, especially if hernia co-exists, a radical opera- 
tion for the closure of the neck of the sac may be undertaken. 

Encysted hydrocele of the cord or testicle, when of such dimensions 
as to cause inconvenience or pain, may be treated exactly as if an 
ordinary chronic hydrocele of the tunica vaginalis. It may be tapped, 
and should the fluid continue to re-accumulate after successive tappings, 
ijdine, carbolic acid, or other irritating liquid may be injected, and 
should failure still follow, an incision may be made and the cavity 
drained and dressed antiseptically. 

HYDROCEPHALUS, Acute— See Meningitis. 

HYDROCEPHALUS, Chronic. 

The treatment of this malady can only be palliative. Everything 
should be tried which can be expected to improve the faulty nutrition 
upon which the diseased condition is probably depending. In those 
cases where the accumulation of fluid is believed to be caused by the 
pressure of scrofulous tumors, the various means by which the strumous 
condition can be improved may be employed with some hope. (See 
Scrofula.) 

Where the condition supervenes upon the acute affection, or where 
it is supposed to be owing to an idiopathic dropsy, counter-irritation of 
the scalp by iodine or cantharides, has been recommended, but little is, 
however, to be expected from this treatment. In very young subjects 
the careful inunction of mercurial ointment has given some decidedly 
satisfactory results. It cannot, however, be pushed far without doing 
harm. Iodides internally, in combination with bromides, afford the 
best chance of improvement. The writer believes that there is no 
means by which the nutrition of the body can be so rapidly improved 
as by the inunction of cod-liver oil in the way described under the 



HYDRONEPHROSIS. 373 

heading of Mesenteric Glands. It should always have a chance in 
such cases as these under consideration. It may be rubbed into the 
scalp, and cloths saturated with the oil may be worn under a water- 
pro- >f cap. Strapping of the head to prevent increase in size appears 
to be dangerous practice, though sometimes good results have followed 
the pressure of an elastic bandage worn for a considerable time over 
the scalp. Puncture of the cranial bones, or of the space between the 
expanded sutures, can only be thought of as a last resource to purchase 
temporary relief in the final stages of the affection. Purgatives, 
diuretics, or forced abstinence from liquids with a view to diminish the 
vascular tension, and thus reduce the accumulated dropsy in the ven- 
tricles, afford no prospect of success. 

Iodine solutions have been heroically injected into the ventricles 
without producing evident good or evil. Perhaps the best results 
may be expected from an elastic woven bandage applied over cod-liver 
oil applications, with iodides or weak mercurials internally in young 
subjects. 

HYDRONEPHROSIS. 

Where the cause can be traced to the blocking up of the ureter by 
a calculus, the first duty of the physician should be to immediately set 
about putting the patient in the most favorable condition to prevent 
the formation of another calculus in the sound kidney. (See under- 
Stone in the Kidney.) 

Where the tumor is not already very tense and of long duration, 
the simple operation of manipulating it through the abdominal walls 
should have a fair trial. With the anatomical position of the kidney 
and ureter, and their relations to other organs in the abdomen before 
the physician's mind, he may try a series of massage and pressure 
movements with the view of dislodging the calculus, or causing the 
fluid to flow past it into the bladder. This succeeded in one case in 
the hands of Sir W. Roberts, and the writer once believed that he 
caused a partial reduction in the size of the hydronephrosis after a 
prolonged examination, during which the tumor was submitted to a 
good deal of manipulation. This manoeuvre is worthy of a trial, and 
before commencing it the patient's abdomen should be freely poulticed 
or swathed in warm water bandages covered by a piece of stout mack- 
intosh for forty eight hours — a local hot pack. It is needless to say 
that undue force should not be employed. Aspiration or tapping must 
be resorted to when the tumor is tense and of large dimensions. The 
site of the puncture is of importance. The sac should be entered from 
behind, midway between the last rib and the iliac crest, two and a half 
inches behind the anterior superior spinous process on the right side. 
On the left side the best spot is one just in front of the interval between 
the last two floating ribs (Roberts). All the fluid should be removed 
through a moderately fine and long needle. Three results are within 
the reach of possibility : (1) The fluid may not again accumulate 



374 HYDEOPHOBIA. 

owing to the previous destruction of the entire secreting structure of 
the kidney ; (2) the tapping may, by relieving or removing the pres- 
sure and irritation, cause the descent of an impacted calculus into the 
bladder ; or (3) it may be followed by a discharge of the hydro- 
nephrotic fluid into the bladder without the descent of any obstruction. 
These results, though very improbable, have been recorded in isolated 
instances, and justify the operation of tapping before resorting to more 
severe and dangerous measures. Aspiration may be repeated as often 
as the urgency of the symptoms demand, and in most instances is the 
only available means of relieving the distress and prolonging the life 
of the patient. 

Of other measures the operation of establishing a free drainage of 
the sac, or of establishing a permanent fistula, has been followed by 
good results. 

This is accomplished by first performing the operation of nephro- 
tomy by making a free incision into the pelvis of the kidney through 
a wound in the lumbar region. 

To cut down upon the ureter and remove the impacted calculus 
where fortunate signs or symptoms localize its exact situation, is not 
beyond practical surgery. The use of the endoscope may turn out 
invaluable in some cases. 

Nephrectomy affords in some cases the only hope of a permanent 
cure. By a lumbar incision (near the outer border of the erector 
spinas) the kidney and dilated sac may be removed without opening 
the cavity of the abdomen or reaching the peritoneum. 

Some of Morris's reports show that the kidney in these cases with 
the dilated sac can be as easily extracted as an ovarian cyst which has 
but few and recent adhesions. He ligatures the pedicle by surround- 
ing the renal artery first, and afterward the renal vein and ureter by 
kangaroo tendon ligatures. 

A case of hydronephrosis has been recently reported where rest 
in bed, with elevation of the pelvis by pillows, was followed by the 
evacuation of the contents of the tumor through the urethra. 

Landau has published a series of cases where the hydronephrosis 
was intermittent owing to the occlusion of the ureter by torsion, or 
tension in patients with moveable kidney. In these cases, position 
with manipulation or external pressure for the most part succeeded in 
hastening the evacuation of the retained secretion, though some of his 
cases resisted these measures and ended in suppuration. 

Goodhart has recently published two typical cases of hydronephrosis 
which had spontaneously recovered, and he reasons that many patients 
would recover if let alone. 

HYDROPHOBIA. 

The treatment of this terrible malady has within the past few years 
excited a deeper interest than any event in the interest of therapeutics, 
if we except the excitement produced by Koch's statements about 



HYDKOPHOBIA. 375 

tuberculosis. The short space at his disposal prevents the writer enter- 
ing into the history of the brilliant steps which have gradually led up 
to the inevitable discovery of Pasteur. Before entering upon a descrip- 
tion of the methods by which the disease is treated by inoculation, 
something may be said of the means by which it may be hoped to 
prevent or exterminate the malady. 

Rabies is never spontaneous. Always arising from the introduction 
of a virus communicated to man by the bites generally of rabid dogs, 
the spread of the disease may be prevented by measures tending to 
check its transmission among the members of the canine tribe. 

A universal muzzling law is expected to do much in this direction. 
A universal knowledge of the earliest symptoms of canine rabies will 
do more. Universal protective inoculation of dogs will achieve every- 
thing. A bite or wound inflicted upon man by a rabid animal should 
receive the promptest treatment. A temporary ligature when possible 
should be applied to the limb above the bite, and the most thorough 
cleansing of the wound effected. Doubtless many lives have been 
saved by sucking the injured spot with the lips immediately after 
the wound has been inflicted. This procedure cannot be said to be 
absolutely free from danger, though the risk may be regarded as 
infinitesimal. 

After application of the lips, the mouth should be carefully washed 
out and a free expectoration encouraged. The lacerated tissues should 
then be subjected to free and deep cauterization, nitrate of silver 1 being 
the most convenient — in its absence the actual cautery should be used 
without delay. Strong carbolic acid is equally potent and much less 
painful. The bitten or lacerated tissues may be excised with the knife, 
and when this can be done immediately, it will be the most powerful 
of all measures in preventing after consequences. 

Probably of all wounds tuus promptly treated a very small percent- 
age would be followed by rabies (possibly not 5 per cent.). This treat- 
ment, however, to be useful must be carried out without a moment's 
delay. As a matter of fact more or less delay almost invariably occurs, 
and sometimes no attention is paid to the w T ound owing to the viru- 
lence of the animal not being suspected at the time. In any case, even 
prompt cauterization of the wound should not interfere with the 
adoption of further measures, nor should the thought of future inocu- 
lative treatment prevent cauterization at the time. Local treatment of 
the wound, judiciously carried out, must always minimize the danger. 

The wound being inflicted, and the animal being reasonably suspected 
or known to be rabid, or proved afterward to be rabid, the important 
question comes up : Should the patient take his chance of escaping the 
after consequences? The answer must in all cases be in the negative. 

1 The writer has been recently informed by Dr. Eoux that he regards the 
nitrate of silver as one of the least reliable of all caustics for the treatment of 
rabid dog bites. 



376 HYDKOPHOBIA. 

This is obvious when the risks are considered. According to Ruffer, 
at least one person in every seven persons bitten by animals believed 
to be rabid perish from rabies if not treated by the Pasteurian methods. 
Of bites upon the face three at least out of five die, and wolf bites 
upon the face are still more fatal. Many authorities give much greater 
mortalities. 

After Pasteur's treatment of all cases bitten by animals certified or 
proved to be rabid, excluding those dying daring treatment and those 
dying within fourteen days after treatment had been concluded, the 
mortality is a little over i per cent. 

In the year 1888, according to Ruffer, all the cases inoculated at the 
Pasteur Institute numbered 1626. Of these 1.16 per cent. died. Ex- 
cluding those dying during treatment, the mortality was 0.79 per cent., 
and excluding those dying within fourteen days after the completion of 
treatment the mortality was only 0.55 per cent. An examination of the 
face and head bites shows a mortality of about 2.5 as against about 80 
per cent, in the untreated. 

In the very recent paper of Dr. Roux, read at the Congress of 
Hygiene, he gives some interesting 'figures, which show the result of 
the Pasteur treatment from January 1, 1886, to January 1, 1891. 
These figures will include those just given, but as they also include the 
previous years before the treatment was perfected, the gross results are 
not so favorable in some respects as those obtained in any single late 
year. 

Of 9465 patients treated during the five years mentioned, the total 
mortality was 90, or 0.95 per cent. Excluding all the patients dying 
during the days immediately after the treatment before the preventive 
inoculation could have had any effect, the mortality amounted to 0.61 
per cent. He points out the interesting fact that the mortality was 
considerably higher among the foreigners treated at the Institute, as 
these had to travel greater distances, and hence could not get the treat- 
ment so soon after being bitten, as those living nearer to Paris. 

The total statistics regarding head bites for the five years just men- 
tioned show an increase over those of 1888, but the result is most 
striking, and affords, perhaps, the most brilliant feature in this marvel- 
lous triumph of therapeutic enterprise. 

Roux puts down the total mortality of all untreated head bites at 
80 per cent. ; other authorities place it at a higher figure. 710 patients 
bitten upon the head and face by animals proved experimentally to 
have been rabid, or by animals certified by veterinary surgeons to 
have been rabid, were treated during the five years at the Pasteur 
Institute, and the result was a mortality of 3.38 ; only 24 died. 

According to the accepted mortality of untreated head and face 
bites, at least 568 of these would have perished in the absence of the 
Pasteurian method. This shows a saving of live amounting in this 
one group of cases to 544. 

Again looking at Roux's statistics, the reader will see that if he 



HYDROPHOBIA. 377 

accepts the low estimate that of untreated patients bitten by animals 
believed to have been rabid, only one in every seven dies, it will, there- 
fore, be clear that of the 9-AG5 treated at the Institute, at least 1352 
would have perished in the absence of the Pasteurian plan. As only 90 
succumbed, this shows a clear gain of 1262 lives saved in the five years. 

But this is not all. Similar institutes exist in Russia, Italy, Turkey, 
Brazil, United States of America, and elsewhere, and the benefits con- 
ferred upon mankind by Pasteur cannot be overstated. 

The virus producing rabies is believed to contain a living organism 
which has not yet been isolated or cultivated. Bacteria dnring their 
life produce chemical substances which ultimately check or inhibit 
their action, as man secretes substances which if again finding their 
way in quantity into his organism would cause his death. Pasteur 
believes that this suicidal weakness of all bacteria affords the means 
by which their ravages may be checked. His theory is that by inject- 
ing the chemical substance into the system of any animal it may be 
protected from the bacteria which produces this substance. He also 
attaches considerable importance to the action of the attenuated living 
virus, which is injected along with the chemical substance. 

Recently Hankin has isolated a pure albumose from anthrax cul- 
tures by ordinary chemical methods. By injecting this chemical sub- 
stance, devoid of all living organisms, he has proved that he can 
protect an animal from the fatal consequences which would otherwise 
certainly follow the inoculation of the anthrax virus. 

Pasteur has not yet been able to isolate the chemical substance which 
is secreted by the living germs of rabies, but by attenuating the virus 
he has diminished the amount of the living organisms, and at the same 
time increased the amount of the protecting chemical substance. His 
first injections may be regarded, therefore, from a therapeutic point 
of view, as inoculations of this vaccinating or protecting chemical 
substance. 

It is quite possible that in the future, rabies may be scientifically 
treated or prevented by inoculations of some chemically pure albu- 
mose, which possibly may be synthetically prepared from harmless 
substances. 

Roux has, however, quite recently laid stress upon the far greater 
protective influence of the inoculations of attenuated virus than of 
inoculation of the pure chemical substances secreted by the bacteria. 

To prevent the manifestations of a bacterial disease, it would appear 
that the vaccinating substance should be introduced into the system 
before the inoculation of the living virus. Owing to the fortunate 
circumstance that the incubation of rabies in man is so tedious, there 
is left ample time for the rapid action of the vaccinating substance 
before the outbreak of the disease. 

The first step in Pasteur's method is to obtain a definite, strong virus 
which will always produce death in a given fixed time when injected 
into an animal. This powerful virus is only obtained after many 

25 



378 



HYDROPHOBIA. 



inoculations, and when procured, its lethal action is singularly uni- 
form. It is developed in the following manner : A rabbit is inoculated 
under the dura mater with the virus from a rabid dog, and an emul- 
sion from the medulla of the victimized rabbit is injected into another 
rabbit, whose medulla is in turn used for the inoculation of a third, 
and so on. After each inoculation the resulting virus becomes 
stronger, and the incubation period shorter, until, as the virus gains in 
virulence, the period of incubation becomes fixed at six days. 

The virus of the dog must be made to pass through eighty rabbits 
before this uniform or fixed virus is obtained. It is then many times 
more powerful than the ordinary virus of a rabid dog. 

A rabbit being inoculated with this fixed virus, takes ill upon the 
sixth day, and dies upon the tenth day after inoculation. If the spinal 
cord of this animal is now removed and exposed in a sterilized jar or 
bottle to air deprived of moisture by the presence of caustic potash, 
and kept at a temperature of 77° F., it is found that every day pro- 
duces a diminution in the power of its contained virus. An emulsion, 
made by rubbing up a portion of the cord before drying, causes rabies 
to appear in an inoculated animal in six days, and death supervenes in 
ten days, as just stated. After drying the cord for eight days, and 
inoculating with it, the animal so treated does not die until about the 
twenty-fifth day. After drying the cord for fourteen days, no effects 
whatever follow its inoculation. 

Pasteur's method of treating patients bitten upon the limbs or trunk 
by rabid animals is, as soon as they present themselves upon the first 
day, to inject an emulsion of the spinal cord, which has been dried for 
fourteen days, and also an emulsion of a cord dried for thirteen days. 
The emulsion is prepared by crushing about J a cubic centimetre (equal 
to the volume of about 7 J minims of water) of the rabbit's cord in about 
30 minims of sterilized beef-tea, and the injection is made under the 
skin of the abdomen. 

Probably no living organism is contained in these injections, or in 
those administered upon the second day, only vaccinating substance 
being found in them, in the opinion of Ruffer. The second day two 
injections are also made, one from a cord of twelve, and another of 
eleven days' drying. 



Third day 
Fourth day 
Fifth day 
Sixth day 
Seventh day 
Eighth day 
Kinth day 
Tenth day 
Eleventh day 
Twelfth day 
Thirteenth day 
Fourteenth day 
Fifteenth day 



Injections from cords dried during 10 and 9 days. 

" • 8 and? " 

Two injections from a cord dried during 6 " 

One injection " " " " 5 " 

4 " 

3 " 

5 " 
5 " 

4 " 
4 " 
3 " 
3 " 



HYDROPHOBIA. 379 

Where the bites have occurred upon the face, or where the bites 
have been inflicted by wolves, the above simple method has not been 
found to act with sufficient rapidity, as the incubation in face bites is 
very much shorter than in ordinary cases. 

For these cases the intensive method is employed, and the following 
figures from Rurfer show how this is carried out : 



First day . 


Injections from cor 


ds dried for 14, 13, 12, and 11 


Second day 




it a 


a 


tt 


10, 9, 8, and 7 


Third day 


Two 


injections 


from a cord dried for 6 


Fourth day 


One 


injection 


it 


a 


" 5 


Fifth day ' 


" 


" 


a 


" 


5 


Sixth day 


" 


" 


a 


it 


4 


Seventh day 


a 


a 


a 


it 


3 


Eighth day 


" 


" 


a 


a 


4 


Ninth day 


it 


" 


" 


a 


3 


Tenth day 


tt 


a 


u 


tt 


5 


Eleventh day . 


" 


tt 


a 


a 


5 


Twelfth day . 


it 


a 


a 


a 


« 4 


Thirteenth day 


a 


a 


a 


n 


4 


Fourteenth day 


u 


" 


a 


a 


3 


Fifteenth day 


a 


a 


a 


a 


3 


Sixteenth and seventeenth days- 


-No 


injections 




Eighteenth day 


One 


injection 


from 


a cord dried 5 


Nineteenth day 


" 


" 


a 


a 


4 


Twentieth dav 


a 


a 


tt 


a 


3 



It may be said that suppuration never occurs at the seat of injection. 
This is owing to the scrupulous care which the writer has personally 
witnessed in every department of the work done at the Pasteur 
Institute. 

Where the symptoms of rabies appear in a patient previously bitten 
by a rabid animal, treatment should be directed to the relief of the 
distressing symptoms. There are a few cases on record where the 
patient has been reported as cured, but most authorities regard these 
cases as very doubtful. The result may be looked upon as fatal once 
unmistakeable symptoms of the disease show themselves. Nevertheless, 
there are some agents which should obtain a fair trial. The writer's 
experience is limited to two cases, which, it is needless to say, resisted 
all the remedies available. 

The patient may be placed in bed in a very quiet and darkened 
room, and as few people as possible should be permitted to congregate 
about his bedside. Hypodermic injections of morphine, or opium and 
chloral by the bowel, afford some measure of relief to the suffering 
when chloroform or ether inhalations cannot be tolerated. 

Kapid mercurialization by rubbing in the U. S. P. ointment, or by 
the mercurial vapor bath, has been tried, and was at one time con- 
sidered as capable of destroying or eliminating the poison. 

Every known narcotic has been unsuccessfully tried to prevent 
the spasms or convulsions. Nitrite of amyl, nitro-glycerin, Calabar 



380 HYDKOTHOEAX — HYPOCHONDRIASIS. 

bean, aconite, belladonna, stramonium, Indian hemp, cold affusions, ice 
to the spine, monobromide of camphor, arsenic, bromides, antipyrine, 
cantharides, etc., have signally failed. Inhalation of oxygen has been 
said to have been once successful. The best results may be hoped from 
curare; if by its use the patient's life may be prolonged, there may be 
a faint hope that nutrient enemata, mild restraint, and perfect tran- 
quillity may keep him alive till the poison is eliminated. Curare 
should be given in large doses ; y 1 ^ to J grain may be injected every 
twenty minutes until there are evident signs of general loss of muscular 
power. 

Lucas Benham has recently published a series of cases of hydro- 
phobia cured by large blood-lettings. 

Tracheotomy may possibly be indicated in threatening death from 
laryngeal spasm. 

HYDROTHORAX. 

If this term be used to embrace the effusions of fibrino-serous liquid 
found in inflammatory conditions of the lining membrane of the chest, 
the reader will find their treatment mentioned under pleurisy. If, 
however, by the term hydrothorax are meant those cases where the 
pleural cavity (generally both sides) contains more or less passive 
dropsical liquid, the treatment will be found under Bright's disease. 

HYPERIDROSIS— See Perspiration, Excessive. 

HYPERM ETROPI A. 

As the blurring of vision in this condition arises from an error of 
refraction — the focus of entering parallel rays falling posterior to the 
retina — the condition in ordinary cases is easily remedied by suitable 
convex glasses, which neutralize the hypermetropia. Where the hyper- 
metropia is severe it is best to correct it fully, especially in children, 
w T ith glasses which should be worn constantly. If strabismus is present, 
such glasses will remedy this complication, provided it be not constant, 
When the squint is constant an operation will be required. In the 
case of older subjects, convex glasses of different strengths are required 
for near and distant vision. 

HYPOCHONDRIASIS. 

The treatment of this affection is most troublesome, and often most 
unsatisfactory. The physician having satisfied himself by thorough 
and painstaking examinations that there is no organic disease present, 
finds himself placed in a difficulty. If he obeys his instinct and pro- 
ceeds to impress upon his patient the view that his symptoms are 
purely imaginary, and if he makes light of his sufferings or painful 
sensations, he only aggravates matters by causing him still further to 
concentrate all his faculties upon his abnormal feelings. Upon the 



HYPOCHONDRIASIS. 381 

other hand, the physician may feel that to encourage the patient's 
consultations and to continue to accept his fees is to compromise his 
own sense of rectitude. It is perhaps for this latter reason that hypo- 
chondriacs are continually driven from one physician to another, much 
to their injury. 

Though the treatment of these patients is most disagreeable, it is the 
duty of the humane physician to strive and relieve their distress as 
much as it is clearly his duty to minister to the sufferings of the lunatic 
or of the victim of hysteria, The disease is a true neurosis, differing 
by clearly- denned lines from melancholia upon the one hand and 
hysteria upon the other. 

Every department from the highest standard of health must be 
carefully investigated. Dyspepsia, anaemia, constipation, gout, and 
other conditions when present are to be met by appropriate remedies. 

Open-air exercise, especially if carried out in the company of others, 
boating, bathing, fishing, golf, or any active amusement in which the 
patient's mind is lifted off his everlasting sensations will do more than 
physic. Travel, if the patient's means permit of it ; if not, when pos- 
sible, a complete change of employment may be advised. Resorting 
to hydropathics or places where invalids congregate often does harm. 
Occasionally, however, the patient returns somewhat improved, but 
with new combinations of sensations derived from comparing notes with 
his suffering brethren who flock about most health resorts. As a rule, 
anything which ensures a complete change of habits and of thought is 
likely to be followed by benefit. By taking and showing a real inte- 
rest in the sifting out of his symptoms, the physician should try and 
gain the confidence of the hypochondriac, after which his calm, firm 
assurance of the absence of any serious disease sometimes does much 
to dispel the patient's malady if in the early stages. ]STow and then 
one meets with instances of superior intellectual power among the 
victims of this disorder, and the writer has had successful results by 
taking such patients entirely into his confidence and explaining to 
them the nature of the neurosis from which they suffer. 

The worst cases, and those which tax the physician most severely, 
are those occurring in patients who exhibit a strain of insanity in their 
family histories, such can only be influenced by the tact, judgment, 
and devotion of their immediate friends. Any attempt to dispel the 
patient's fancies by directly reasoning him out of them generally ends 
in the physiciau losing his influence for good over the sufferer. This 
must be accomplished indirectly through his friends. 

Should drugs be prescribed in cases of confirmed hypochondriasis ? 
Though the answer is a difficult one, the writer does not hesitate to say 
that they should never be prescribed for the sake of humoring the 
patient in his whims. There are few patients, who have long suffered 
from the disease, who do not show some clear indication for consti- 
tutional or local treatment. When this can be conscientiously carried 
out by the physiciau, it may increase his power over the patient for 



382 HYPOSPADIAS — HYSTEKIA. 

good and prevent his falling into the hands of quacks and unscrupu- 
lous persons. Medicine should not be prescribed for the hypochondriac 
as a specific for his ailment in any case, it should always be considered 
as secondary in importance to the moral treatment. Of the host of 
drugs recommended, the writer has only seen decided benefit follow 
arsenic, when given in small doses for lengthened periods, the following 
is a simple formula : 

R. — Liq. potas. arsen TTtxl. 

Tinct. ferri chlor. . . . . . . • 3 ij- 

Tinct. sumbul 3 ij. 

Aquse camphorae . . . . . ad ^ iv. — M. 

S. — Take a teaspoonful three times a day, after meals, in a wineglassful of 
water. 

Strychnine often aggravates, and there is a concensus of opinion that 
alcoholic stimulants and opiates or cocaine should be strictly avoided. 
Relief may be obtained for short intervals by large doses of valerian, 
and by small doses of antipyrine. One asafoetida pill, given at bed- 
time every night, can do no harm. The constant current or static 
electricity may be tried with benefit in some cases. 

Where the hypochondriasis shows itself chiefly as an abnormal ex- 
aggeration of the symptoms or sensation of some trivial local disease, 
judicious and successful local treatment should be persevered with in 
addition to moral treatment. 

HYPOSPADIAS. 

The treatment of this malformation requires varied, and sometimes 
extensive plastic operations, the description of which is outside the 
scope of the present volume. The reader is referred to the article by 
Professor Wood in Heath's Dictionary of Surgery. Minor degrees of 
the deformity may be left uncorrected since they may cause little in- 
convenience. The writer exhibited, some years ago, a specimen of 
artificial hypospadias, which he found in an aboriginal of the interior 
of Australia. He ascertained from an explorer that at least one tribe 
in the centre of that continent performs the serious operation of slitting 
the male urethra open from the glans backward, through the perineum 
toward the bladder, evidently with the view of preventing procreation. 
A careful examination of the specimen proves to what extent the most 
serious plastic operations may be carried out when recovery follows a 
barbarous mutilation, undertaken without anatomical knowledge, and 
performed with the crudest of instruments, and without the slightest 
conception of the necessity of antiseptic precautions. 

HYSTERIA. 

Upon the first indications of the presence of hysterical tendencies, 
the general health of the patient should be carefully looked into. Her 



HYSTERIA. 383 

diet should be liberal, and administered with frequency and regularity. 
Active open-air exercise should be insisted upon, even to the extent of 
producing some fatigue. Regular hours for rest are essential. Every- 
thing which over stimulates the cerebral centres is to be avoided, as is 
also every excitement of the emotions or passions. Healthy and con- 
stant mental occupation should be advised, with avoidance of the evils 
attendant upon social dissipations, with their late hours and unnatural 
excitements. Sound, wholesome literature, instead of the maudlin, 
sentimental trash of cheap novels, should be supplied as food for the 
mind, care being taken that the patient be not permitted to tax the 
memory or perceptive faculties too severely. Sea-bathing or the morn- 
ing cold bath, when admissible, are valuable adjuncts, and the patient 
should be strongly advised to retire early to bed, and to persist in early 
rising. 

Any departure from the healthy standard in digestion or assimila- 
tion requires to be remedied. Anaemia calls for iron, and menstrual 
disorders and constipation demand appropriate treatment. 

Where the symptoms have become established, preventive treatment 
is, of course, out of the question, but the above general measures may 
be applied with benefit in any stage of the affection. 

Moral treatment is of first importance in every case, and if the men- 
tal constitution of her immediate friends and relatives does not permit 
of their treating her with firmness, her removal to less sympathetic and 
more reliable companions, or strangers, is advisable. In very con- 
firmed cases, as will be presently mentioned, rigid isolation must be 
insisted upon. The physician should take her relatives into his confi- 
dence, and make it clear, beyond the possibility of being misunder- 
stood, how her case stands. This is generally only half attempted, and 
her friends too ofcen interpret the physician's remarks as meaning that 
the patient is either malingering or laboring under some delusions or 
fancies. Consequently their management of her, with this erroneous 
impression, is fraught with disaster. The cooperation of a strong- 
minded, judicious relative, possessing tact and firmness, though not 
devoid of sympathy, but capable of suppressing her sympathetic mani- 
festations, is of infinitely more value than all the drugs at our com- 
mand. 

The influence of such a mind operating upon the victim of hysteria 
can be guided by the physician in such a way as to strengthen the 
patient's will power, and enable her to successfully combat the tendency 
to yield to displays of emotional disturbances. Lecturing or scolding 
the patient continually is to be condemned. Each case must be man- 
aged as the judgment and tact of the physician directs. Sometimes 
the influence of the strong will of the physician may accomplish results 
which appear as miraculous. The writer had the satisfaction of being 
able upon one occasion to cause a patient who was bedridden for several 
years to get up and walk across her room, to the amusement of her 
relatives, who had regarded her as hopelessly paralyzed. There can- 



384 HYSTERIA. 

not be a doubt that very many of the so-called examples of faith-heal- 
ing are instances of this therapeutic power. 

While upon the moral treatment of hysteria, the reader may glance 
at the remarks made under the head of Hypochondriasis, on page 380. 

As regards the use of drugs in benefiting the general hysterical con- 
dition, it must always be remembered that they should be considered 
as of secondary importance when compared with the moral treatment. 
Valerian has long enjoyed the reputation of being the most valuable 
member of this class of remedies. To be of any use, however, it must 
be given in doses much above the strength of those usually employed. 
Drachm doses of the simple tincture, or an equal quantity of the am- 
moniated preparation, freely diluted, may be given three or four times 
a day. 

The valerianate of zinc or of iron is undoubtedly the best remedy 
which we possess for constant administration in those cases of general 
neurasthenia or hysteria, whether occurring in the emaciated or ple- 
thoric subject. The writer has given the zinc salt in doses of 5 grains 
three times a day as long as the patient's stomach has tolerated it. 
After nausea or loss of appetite appeared to result from these large 
doses, he generally found the accompanying pill to be the most satis- 
factory routine treatment : 

Be . — Zinci valerian. -\ 

Quininse valerian. > aa gr. j. 

Ferri valerian. J 

Ext. aloes aq. . . . . . . . . gr. ss. — M. 

Make 24 of these. 
S. — Take one pill, after meals, three times a day. 

Asafoetida is sometimes very useful. Five grains in pill, morning 
and night, may be given, and should there be much constipation, 10 
grains of the tJ. S. P. pill may be given at bed-time. 

Musk is useless, and sumbul is generally disappointing. 

Bromides are of little service unless in special cases to be mentioned. 
Their routine administration especially in lean or so-called neurasthenic 
subjects is productive of much mischief. 

Strychnine is recommended by some authorities. The writer has 
used it extensively in varying doses, and never saw it administered 
without causing aggravation of the symptoms. Recently Ingals has 
reported marked success in hysterical aphonia by pushing the drug 
from doses of -£$ grain to j 1 ^- grain until physiological symptoms appear. 

Aetata, or cimicifuga, arsenic, pellitory, oil of amber, ignatia, camphor, 
galhanum, bromide of camphor, garlic, cocaine, antipyrine, and many 
other substances have been used in a routine way in hysteria. Those 
of them which the writer has tried have been useless or harmful. It 
is to be regretted that the multiplicity of so called remedies tends to 
divert the physician's mind from the moral and rational treatment of 
the disease, from which alone the best results are to be obtained. 






HYSTERIA. 385 

Alcohol should be avoided, and narcotics are to be prescribed with 
caution, and such restriction should be imposed as will ensure the 
patient against the dangers of becoming enslaved to their use. The 
cocaine habit must also be guarded against. 

Suspension has been tried in some cases, and reported upon favor- 
ably, but further experience is required before its utility can be estab- 
lished. It is carried out in the manner detailed under Locomotor 
Ataxia. 

Before proceeding to detail the special treatment indicated for the 
various local manifestations of hysteria, a brief description of what is 
known as the Weir Mitchell Method may be given. By this treatment 
cases have been brought under easy and rapid control, which hitherto 
have been considered altogether outside the sphere of practical treat- 
ment. 

The feature of greatest importance in this method is the isolation. 
This must be thorough and complete, only the nurse, physician, and 
masseuse being seen by the patient during the treatment. As a rule, 
it may be said that the other elements in the treatment are worthless 
without this strict isolation. Owing to the objections of the patient 
and her friends much opposition is encountered in carrying out this 
method in its entirety, but it may be advised that unless they agree to 
this rigid isolation it is useless to proceed with the plan. 

The patient must be removed from her own home to an institution 
in which suitable provision is made for the reception of such cases, or 
she may be brought to comfortable lodgings. 

The second element in Weir Mitchell's method is absolute rest in 
bed, the patient not being permitted even to stand upon her feet for a 
moment, just as if she were suffering from severe typhoid fever. She 
is not permitted to use her arms or hands, being fed by the nurse as a 
child. Letters, books, sewing, and other ordinary harmless occupa- 
tions are forbidden for the first few weeks, after which she may be 
read to for a short time, and gradually these measures are relaxed ; 
but for the first six weeks the horizontal position should be maintained 
in severe cases. 

Overfeeding is the third feature in the treatment. Milk alone should 
be given for the first ten days, at frequent intervals, until enormous 
quantities are consumed. After three or four days sometimes 8 or 10 
pints are swallowed daily. Strong beef-tea, chicken soup, meat jellies, 
tea, coffee, chops, fish, steaks, poultry, eggs, bread and butter, oysters, 
oatmeal porridge, vegetables of all kinds, puddings, and any form of 
plain, wholesome, digestible food are administered in very large 
quantities. 

Massage is an important part of the treatment. It should be com- 
menced upon the third day and be carried out in the most thorough 
manner, gradually extending the dose until an hour's good deep knead- 
ing of the muscles and tissues of the body can be borne by the patient. 
In bad cases, two applications or doses lasting for three-quarters of an 



386 HYSTERIA. 

hour each, morning and evening, may be required. At the beginning 
it is well to confine the operations to the extremities, and the move- 
ments should be limited to the superficial structures. Afterward the 
deeper tissues and muscles may be kneaded until in a few days the 
entire body, excepting the head and face, receives a fair share of 
manipulation. In this way the blood and lymph circulation is greatly 
stimulated, effete products are washed away, waste materials being 
removed, and fresh pabulum brought with great rapidity to the re- 
freshened tissues. 

The enormously increased amount of nourishment is -thus used up 
to the greatest advantage, and the patient's body-weight increases to 
an astonishing extent. Wasted muscles and emaciated limbs become 
plump and agile, and the change in the patient's aspect and dimensions 
is such in ten or twelve weeks' treatment as to tax the credulity of 
those who had not previously witnessed examples of the method. 

Electricity is the last element in the Weir Mitchell plan of treating 
hysteria or neurasthenia. The uses of electricity will be more fully 
mentioned under the head of the treatment of the local manifestations 
in the following few pages. When used as a portion of this method, 
it is employed as an adjunct to massage. The interrupted strong cur- 
rent is selected, and the various muscles or groups of muscles are 
thrown into contractions. 

This treatment has been productive of the greatest good in cases 
apparently hopeless, but, like every other powerful agent, its use has 
been abused, and in some cases the disease has been aggravated by its 
employment. As a rule, those so-called cases of neurasthenia (hysteria 
associated with great emaciation) are successfully treated by it. Stout 
subjects suffering from hysteria as a rule do not improve, and often get 
worse under its use. 

For the special symptoms manifested in hysteria, special treatment 
may be demanded. 

Convulsions. If the physician be called to a patient during an attack 
of convulsions or of hysterical coma, and if he be confident of the 
accuracy of his diagnosis, he can have the satisfaction of often bringing 
the fit to an abrupt termination. 

The patient, if in bed or upon a sofa, is so placed as to enable the 
physician to pour a stream of cold water suddenly from a height upon 
her face without saturating the bed-clothes or garments of the patient. 
This free douching is soon followed by a return to complete conscious- 
ness, and in subsequent fits the mention of it is often enough to arrest 
all symptoms. Sometimes a tumblerful of cold water thrown forcibly 
against the face acts like magic ; but the physician should state in the 
hearing of the patient that the application is to be repeated every two 
or three minutes until she gets out of her attack. 

Catching the patient by the nose while the mouth is kept closed, so 
as to arrest the breathing entirely for a short period, may arrest an 
attack instantly. Strong liquor ammonia to the nostrils may produce 
the same effect. 



HYSTERIA. 387 

Pressing- deeply over the region of one ovary is said to sometimes 
arrest a fit of convulsions or of coma, but it often fails ; and when it 
does appear to arouse the patieut it leaves her in a very excited and 
excitable condition. 

Electricity is of value if at hand; and by placing one electrode over 
the front of the neck and the other over the pit of the stomach, a smart 
interrupted current may stop the paroxysm in a few seconds. It has 
no such effect in epilepsy, and may be used, therefore, as a means of 
arriving at a positive diagnosis of the nature of the fit. 

Hypodermic injection of apomorphine, to produce vomiting, has been 
recommended in hysterical opisthotonos. 

Deep pressure upon the arteries and tissues at the base of the neck, 
so as to interfere with the cerebral circulation, as is sometimes success- 
fully tried in stopping epileptic fits, may cut short the attack of hysteria 
or of hystero epilepsy. 

While carrying out these measures, the room should be cleared of 
all active sympathizing spectators, and the physician should give his 
orders and carry out his operations without the least sign of hesitancy 
or wavering. This latter he cannot do unless he be very positive about 
his diagnosis ; indeed, little can be done with hysterical patients as 
long as the physician has any doubt whatever lingering in his mind 
about the case being one of genuine hysteria. The patient by intui- 
tion recognizes his want of confidence in himself, as shown by some 
very trivial circumstance, and the result is that the demon refuses to 
be exorcised. 

Where the coma has lasted for a considerable time, and the douche 
or electricity has failed, the application of a hot cautery iron gives 
prompt results. • The writer has cut short attacks of both convulsions 
and coma by giving directions, in a loud and firm tone of voice, for 
the heating of an iron and the ordering of a portion of the skin to be 
exposed for cauterization. He has, however, never seen a case where 
the actual carrying out of this measure appeared to be justified. Nitrite 
of amyl sometimes arrests the paroxysm. 

After the arrest of the paroxysm of coma, or convulsions, or de- 
lirium, much remains for the physician to do. The patient should be 
compelled to attend to all those points already detailed in the com- 
mencement of this article, and she should have full doses of the am- 
moniated tincture of valerian, with some asafoetida, administered at 
short intervals. The valerianate of zinc, in 3 grain doses, may after- 
ward be prescribed for several weeks. 

The following nauseous and disgusting combination may be tried : 

R. — Tinct. asafoetida ^j. 

Tinct. valer. ammon. . . . . . . 3jij. 

Olei terebinth] me gij. — M. 

S. — Take a teaspoonful in a wineglassful of water every second hour (shaking 
the bottle). 



388 HYSTERIA. 

Local paralysis should be treated by the means recommended as 
useful for the general hysterical condition. Massage, passive motion, 
and electricity, locally employed, afford, in conjunction with moral 
treatment, the best hope of success. The same measures prove useful 
in dealing with contractions or flexions, which are also successfully re- 
moved by the application of a circular blister around the joint. The 
method of employing these therapeutic agents will vary with the 
locality and nature of the affected parts or organs. 

Aphonia yields readily to electricity, which may be employed in 
various ways for the treatment of this affection. By the aid of the 
laryngeal mirror one electrode is placed in contact with the vocal 
cords, the other being fastened to the outside of the larynx. By a 
button in the handle of the interior electrode the current is turned on, 
and the shock often causes the patient to instantly find the use of her 
voice, perhaps for the first time for many months. The applications 
should be repeated until the aphonia entirely disappears. Sometimes 
one sitting of a few minutes suffices, but more commonly several are 
required to insure that no return of the aphonia occurs, The faradic 
or interrupted current should be used, and contact may be made five 
or six times during each sitting. (See also under Aphonia on page 
50.) 

In the absence of the special electrode required for carrying out 
electrization of the vocal cords, good results may be obtained by pass- 
ing a smart interrupted current through the larynx by means of 
moistened sponge electrodes placed externally over each side of the 
larynx in the neck. Static electricity may be used ; it is, indeed, in 
this case much more certain than galvanic currents, and its effects are 
more lasting. It may be used in a variety of ways, the simplest being 
that of passing a series of shocks through the larynx from a Ley den 
jar. As the aphonia is, however, only one of the many manifestations 
of the hysterical state, it will be advisable to administer the static 
electricity in a way that will affect the entire system. The simplest 
and mildest method of using it is to place the patient on an insulated 
stool, or in an insulated chair, and by means of a brass rod held in 
her hand to connect her body with the prime conductor or condenser 
of a Carre, Holtz, or a Wimshurst machine. This is called the " static 
bath." When the surface of the patient's body becomes thoroughly 
permeated by the positive fluid, the physician approaches with a large 
wooden ball which he holds at about the distance of an inch from the 
patient's skin, the electricity passes from the patient through the ball 
and the operator's body to the ground without producing pain. This 
is known as the " electric souffle." 

To produce the " electric spark," a metal ball electrode or metal 
point is brought sufficiently near to the patient's body to cause a sudden 
di? charge of positive electricity. 

In hysteria excellent results have been obtained by Dr. McClure. 
His routine method of procedure is to insulate the patient, and for the 



HYSTERO-EPILEPSY. 389 

first two sittings to administer the " bath," afterward by bringing the 
wooden ball close to the skin, but not close enough to produce a spark, 
he moves it in all directions over the body. When the paralyzed part 
or an area of anaesthesia is approached, the ball is laid aside, and sparks 
(light or heavy) are extracted by means of metal electrodes. In this 
way sparks may be extracted from the larynx in hysterical aphonia 
with much advantage. 

Owing to the difficulties in working with static machines, static elec- 
tricity has not received the attention which it deserves. 

General faradization may be employed in hysteria, as static electricity 
is administered by the static bath. 

The patient stands upon a large metal disc or moistened sponge 
electrode connected with the negative pole of the battery. While the 
physician places himself in connection with the positive pole through 
a wire held in one hand, with the other hand he holds in contact with 
the patient's body a large metal ball enveloped in a moistened sponge. 
The current thus passes through his body, and also through the patient 
as it passes from pole to pole. Either the galvanic or faradic current 
may be used. 

These are the principal ways in which electricity is employed in 
hysteria, and it is often impossible to tell which method is the best in 
a given case until it has been tried. Each method is also capable of 
being varied. Thus in the treatment of neurasthenia cerebralis, where 
insomnia is the chief trouble, static electricity may be administered 
by holding the large wooden ball in front of the forehead of the 
patient sitting in the insulated chair, or the metal cap electrode may 
be used with great advantage. The writer has had excellent results in 
such cases by passing a weak, continuous, or galvanic current through 
the brain by using two sponge electrodes outside the skull, or con- 
nected with four or eight large Leclanche cells. The use of what is 
known as "static induction" is not yet sufficiently recognized thera- 
peutically to warrant a description. The same may be said of the 
nature of galvano-faradization. 

For ordinary cases of paralysis occurring in limbs in hysteria the 
use of the interrupted current locally, generally meets all the require- 
ments of the case. Cutaneous hypersesthesia and anaesthesia may be 
dealt with in the same way. When these fail, the general methods 
should be- resorted to with the treatment already mentioned. 

HYSTERO-EPILEPSY. 

This formidable affection can only be hoped to yield to the meas- 
ures already enumerated when discussing the general treatment of the 
hysterical condition. The writer has had splendid results from amyl 
nitrite in stopping the attacks in one well-marked case of the disease. 
Pilocarpine, hypodermically, has been used to cut short the convulsive 
attacks. In preventing the attacks, bromides and arsenic were decid- 



390 ICTHYOSIS. 

edly useful, but total absence from alcohol and butcher's meat gave 
better results than drugs. 

ICHTHYOSIS. 

Internally, drugs are practically useless. There are some physi- 
cians who have still a remnant of faith in arsenic and cod-liver oil, but 
it is to local treatment that the physician must look for amelioration 
of the symptoms of this disorder. 

All the dead epithelial products should, as far as possible, be re- 
moved before any local remedies are applied. This is best carried out 
by prolonged immersion in a warm weak alkaline bath, with the free use 
of a pure soft soap, and moderate friction by means of a soft hair bath- 
glove. The Turkish bath may be afterward employed with advan- 
tage, or any form of convenient hot air or vapor bath may be used. 
When the scales or plates have been removed, a bland, unirritating 
animal oil or fat should be gently rubbed in until the skin is brought 
to the natural suppleness. Lard oil or neat oil is the best, but any 
vegetable oil may also be used, and 'a pure olive oil, such as is used 
for salads, is free from objectionable odor. Vaseline or glycerin may 
be used for the exposed parts of the body, but upon the whole, the 
face and hands are best treated by pure lanoline, which should be 
gently rubbed in until it disappears. 

The bath should be used once each day for long periods, but the 
inunctions should be performed twice a day. When the skin has been 
brought to its natural feel and appearance, a hot bath once or twice a 
w r eek and a daily application of the oil will keep the subject of simple 
ichthyosis in a tolorably comfortable and presentable condition. 
Mild cases get on with one thorough inunction in the week. In a 
case occurring in a weak, thin boy, the writer had an excellent result 
from one thorough application of cod-liver oil every week. Suet or 
cacao butter answers Avell in some cases. 

In severe cases of ichthyosis hystrix, where there is much harden- 
ing, the callosities may be gently scraped or rubbed down with a 
curette, or dissolved by application of a lotion consisting of one part 
of the liquor potassse in two parts of water. 

Salicylic acid, dissolved in collodion, may be more conveniently 
used to destroy the growths, and it will not cause injury to the under- 
lying skin. After the removal of the cakes, an ointment containing 
10 grains of iodide of potassium in solution, rubbed up with 1 ounce 
lanolin, may be used with advantage. Ichthyol and resorcin (10 per 
cent.) or naphthol (5 per cent.) ointments may be tried in the later 
stages of treatment. Pilocarpine, hypodermically, has failed to give 
any result to warrant its prolonged trial. 

Where eczema complicates the case, the red, weeping fissures must 
be treated by emollients before resorting to frictions. 



IMPETIGO — IMPOTENCE. 391 

ICTERUS— See Jaundice. 
IMPETIGO. 

As there is always present some considerable departure from health 
upon which the pustular eruption depends, the treatment should be 
directed to the cause. The diet should be plain and nutritious with- 
out being too stimulating. Fresh air, exercise, and every means by 
which the standard of health can be raised, should not be neglected. 
Anaemia, constipation, dyspepsia, and other troubles are to be met by 
appropriate remedies ; and tonics, with cod liver oil and malt extract 
are afterward to be given. 

Locally, the treatment may be rationally carried out by regarding 
the disease as if it were a purulent eczema. 

The remedies suitable in eczema impetiginoides are indicated. After 
removal of scabs or crusts by warm fomentations if the case has been 
neglected, the seat of the eruption should be generously smeared over 
with ointment of zinc, or with a cream made by rubbing up equal 
parts of lime-water and olive oil with oxide of zinc, or carbonate of 
zinc. 

When the scalp is affected, warm bread and water poultices will be 
often required in addition to persistent sponging until the crusts are 
removed, after which the hair should be cut close, and an ointment 
consisting of one part of white precipitate ointment and three parts of 
zinc ointment should be freely applied. Impetigo contagiosa yields to 
the same remedies. 

IMPOTENCE. 

When this arises from surgical or mechanical causes operative 
measures may remedy the failing. The cause, when not depending 
upon mechanical obstacles, should be ascertained before treatment is 
attempted. Many of the cases seeking advice from the physician are 
in those recently married, and much mischief may be done by the 
administration of powerful drugs under these circumstances. The 
situation arises from ignorance and nervousness, and produces some- 
times a dangerous depression of spirits. The vast majority of cases 
of this nature right themselves in a few days if left alone, and all that 
is generally necessary is a little sound advice and no drugging. The 
stereotyped instruction to rigidly abstain for a time from all attempts 
at sexual intercourse is a mistake, unless under special circumstances ; 
nature generally sets matters right in a short time. This is especially 
true in those cases where emission occurs before penetration has taken 
place, and then a successful ccitus may take place when the act is 
attempted again within a short time after failure. 

Moral treatment is all that is necessary in most cases where the 
incapacity is imaginary. Where impotence arises from previous recent 
excesses, but where the generative organs have not apparently suffered 



392 • IMPOTENCE. 

structurally to any obvious extent, total abstinence from all attempts 
at intercourse must be rigidly advised until evidence is forthcoming 
that nature means to assert herself. During this period vigorous ex- 
ercise, with good living, abstinence from alcohol, with the daily use of 
the cold shower-bath or sea-bathing and tonics, are very useful. 

Of tonics, iron, in full doses of the tincture of the chloride in com- 
bination with strychnine, is the best. Easton's syrup of the phos- 
phates is a valuable preparation. It should be given in doses of at 
least one drachm three times a day. 

The ordinary members of the aphrodisiac class, as a rule, do harm, 
and should not be prescribed in these cases. The mere production 
of an erection is a very different thing from power to perform the 
sexual act successfully, and these artificial aids generally fail, and 
after each failure the position of the patient is decidedly worse. For 
this reason he should be urged not to attempt the act until he feel that 
he has reason to believe that the attempt will be more successful than 
the last. In most cases the patient's own sensations will be his guide 
in this point. 

If, however, this treatment fails to cure the impotence, other meas- 
ures remain, and these may at once be resorted to without waiting in 
those cases of impotency occurring after middle life, or in those who 
have indulged in sexual excesses, or in masturbation to the extent of 
causing atrophy of the testicles or penis. In such cases there is often 
weakness of sexual desire, but sometimes it is not diminished, and the 
physician finds that the mental despondency associated with the im- 
potence is so serious as to call for active treatment. 

Next in value to abstinence and the general hygienic measures just 
mentioned is electricity in the treatment of premature loss of virility. 
This remedy may be used in various ways. The writer has observed 
that the best results follow from the use of a moderately strong con- 
tinuous current. One large sponge-electrode being placed over the 
lower end of the spine, the other is applied to the groin, spermatic 
cord, testicles, penis, and perineum in succession. The sitting should 
last for twenty minutes, and may be repeated twice a day. The inter- 
rupted current may be employed occasionally with advantage for the 
space of about a week, during which the continuous is suspended. 

Massage, or gentle kneading of the scrotum and testicles, followed 
by free sponging of the parts with cold sea-water twice a day, has a 
decided influence in improving the tone and nutrition of the genera- 
tive organs, and should always be tried in conjunction with elec- 
tricity. 

Benefit may sometimes be obtained from the wearing of a good Pul- 
vermacher chain battery around the pelvis or loins. 

Where the secretion of the testicles is not impaired, and where 
there is no abnormal deficiency in sexual appetite, the incapacity 
being mainly or entirely caused by some error in the apparatus neces- 
sary for erection, authorities speak highly of cantharides in small 



INCONTINENCE OF URINE. 393 

doses — 2 to 3 minims of the tincture — or of phosphorus. The writer 
has never prescribed these remedies for this purpose, and is doubtful 
of their utility. Of the so-called aphrodisiacs there is only one, in 
his opinion, which exerts a decidedly beneficial and harmless action in 
loss of virility arising from early sexual excesses or premature decay 
— he has tried it with success which warrants its recommendation in 
such cases — viz., damiana. 

This is a Mexican plaut, the tumera diffusa, which appears to act 
as a mild stimulant to the genito-urinary centres in the cord. (See 
author's work on Materia Mediea, fifth edition, page 555.) It may be 
given in doses of 1 drachm of the fluid extract (1:1) three or four 
times a day, or the following combination may be prescribed with 
advantage : 

H . — Ext. damianse fid ^ ijss. 

Tinct. nucis vomicae . . . . • 5 V J- 

Glycerini q. s. ad ^ iv. — M. 

S. — One drachm three times a day after meals in a wineglassful of water. 

Ergot, sanguinaria, turpentine, serpentaria, cubebs, and other 
vaunted remedies are worse than useless. Where the impotence occurs 
in conjunction with some organic or functional disease, it may reason- 
ably be expected to pass off when the affection is removed, and it is 
needless to say that appropriate treatment should be directed to the 
mischief of which it is symptomatic. Thus, in diphtheritic paralysis, 
lead poisoning, and renal affections, impotence may be the condition 
which first directs the patient's mind to the attack. 

In those cases where the loss of virility supervenes upon head or 
spinal injuries, the best hope of success will lie in the judicious admin- 
istration of small doses of the bichloride of mercury (^ grain), or 
possibly of ^ grain of the chloride of gold and sodium salt, or of 5 
grains of the iodide of potassium. Phosphorous should be used with 
the greatest caution in such cases. After a few weeks or months of 
this treatment, the use of a weak continous current, passed through the 
cerebrum for a few moments and followed persistently with galvanism 
of the spine from the head to the sacrum, will accomplish all that 
drugs can be expected to achieve. A prolonged sea voyage or suspen- 
sion, as for locomotor ataxia, may be tried. It has been noted that in 
locomotor ataxia, after suspension, in some cases impotence for a time 
disappears. The writer has, however, observed the temporary disap- 
pearance of impotence in one very advanced case, where the symptom 
had been marked for many years. In this case suspension had not 
been tried. 

INCONTINENCE OF URINE. 

Where this is caused by surgical affections, as stone in the bladder 
or prostate, the obvious treatment will consist in the removal of the 

26 



394 INCONTINENCE OF URINE. 

cause. Where the incontinence is simply the dribbling from an over- 
distended bladder, the result of urethral or prostatic obstruction, the 
only measure of any value is the judicious and regular use of the 
catheter. 

Incontinence in children is a very troublesome affection, but in the 
great majority of instances it will be found to yield to treatment. It 
is a mistake to regard it as an affection chiefly confined to boys. In 
the writer's experience he has met with it more frequently in girls and 
in the neglected children sent into industrial or charity schools, when 
it is often found in its w T orst forms to be associated with a jow standard 
of intellectual development. 

The absence of any structural cause being determined, either by an 
examination or careful analysis of the symptoms, the physician should 
minutely inquire into the state of the bowels. Threadworms in the 
lower part of the rectum may be keeping up the contractions of the 
bladder, and they should be cleared out by small enemata of common 
salt dissolved in tepid water. In boys, an elongated, contracted, or 
adherent prepuce should be treated by circumcision or dilatation, pre- 
ferably the former. 

Any abnormal condition of the urine should be carefully looked for 
and must be met by appropriate remedies. In very acid urine great 
benefit maybe obtained from the free administration of alkalies in full 
doses during, the day-time. 

The diet should be plain and unstimulating, late meals, and especially 
fluids before bed-time, being forbidden. Restricted diet is a mistake. 
A careful nurse or mother soon finds out what articles of food or what 
beverages are followed by any aggravation of the symptoms, and these 
can be avoided. As a rule, a strong animal food dietary is objection- 
able, but some children are worse upon a pure farinaceous diet, with 
slops. The child should be put early to bed, after a free evacuation of 
the bladder, and lifted by the nurse in three or four hours again, and 
awakened, so as again to have the act of micturition performed. Early 
in the morning this may be again seen to. The bed-clothing should 
not be too heavy, and a hard mattress is preferable to feathers. The 
child should be taught to lie upon either side, and sleeping upon the 
back may be prevented by fastening an empty cotton-reel or spool, by 
means of a tape, round the chest. This will awake the patient when 
he turns over upon his back during the night, and feels the hard sub- 
stance pressing against his spine. This succeeds in grown-up children, 
and is a valuable plan in adults suffering from seminal emissions, but 
it may be tried with very young children. 

Punishment should be forbidden. Such a measure is both cruel and 
useless, except under very exceptional circumstances. 

Blisters applied to the sacrum are generally useless. Dr. Harkin has 
recorded successes in some most obstinate cases by painting over the 
upper cervical spines with blistering collodion, 



INCONTINENCE OF URINE. 395 

Mild cases yield to the above hygienic measures without internal 
remedies, but most cases require the persevering use of drugs. 

Belladonna or atrophine is the best remedy, but as ordinarily ad- 
ministered it is useless. To be of service it must be pushed until the 
physiological action of the drug is obtained in a mild form. It can 
only be of use in doses capable of partially paralyzing the bladder. 
Children bear belladonna well, and some show remarable tolerance of 
the drug. There is, therefore, great difficulty in proportioning the 
proper dose, and no rule can be given to fix the quantity exactly for 
any given age. 

The U. S. P. tincture should always be employed, and a child three 
or four years old may get 2 minims in the afternoon and again in the 
evening before bed-time. This may be gradually increased until 6 or 
7 minims may be reached, if dryness of the throat and dilatation of 
the pupils are not observed. Indeed, it is this great difficulty in 
arranging the dose of the drug which has led to failure. The physi- 
cian must be careful not to leave the increasing of the medicine in the 
hands of inexperienced nurses. 

Too often the physician, through timidity or carelessness, allows the 
case to go on from bad to worse, when a little attention and persever- 
ance would crown his labors with success. There is practically no 
danger in increasing the dose and keeping up the action of the drug 
for two or three weeks, after which it may be gradually diminished, as 
the bladder soon recovers its normal rhythm when the micturating 
habit has been thoroughly broken for a short time. 

There is, however, one important point in the administration of the 
drug which should be remembered. The tincture is made from the 
dried leaves, and these contain very varying amounts of alkaloid. 
Should a weak preparation be commenced with, and increased in 
quantities until, say, 8 or even 10 minins had been reached, and then 
a new sample of the tincture be obtained from another chemist after 
the first had been used up, a stronger preparation might lead to un- 
pleasant results. It will be worth while to see that the same sample 
of the tincture be used throughout the treatment of the case. 

Some physicians recommend the hypodermic injection of atrophine 
One minim of the solution (1 : 100) may be injected in a child of four 
years, 2 minims in a child of ten years, and 3 minims in the case of 
a child of fifteen years. These doses should not be exceeded in the 
first instance ; they may be best administered three or four hours 
bafore bed-time, and half the quantity may be again injected just before 
bed-tipje, if no dilatation of the pupil has been produced. Bromide 
of potassium has now and then given good results, but is very much 
inferior to belladonna. It may, however, be combined with it advan- 
tageously. The following mixture may be prescribed for a child seven 
years old : 



396 INCONTINENCE OF URINE. 

Be . — Potassii bromidi g v. 

Tinct. belladonna? . . . . . . . £ij. 

Syr. simplicis . .' . . . / . . ^j. 

Aquse aurantii flor. . . . . . ad % iv. — M. 

S. — A teaspoonful to be taken every evening at bed-hour. 

Chloral hydrate has been highly recommended — the writer has found 
it to increase the mischief. Like cannabis indica, opium, codeine, and 
other narcotics, it would appear as if the dreaming, which follows the 
administration of narcotics to children, is very liable to excite the 
bladder. 

Rhus aromatica has recently given excellent results. Unna states 
that it acts upon the muscular fibre of the bladder. The writer has 
used it in the case of a young adult with considerable amelioration of 
the symptoms. 

The fluid extract (1 : 1) may be given three times a day in doses of 
5 minims to children under two years, and 10 minims to children of 
eight years old. 

Rhus toxicodendron in small doses has been found to check incon- 
tinence of urine, but in no way is it superior to the rhus aromatica, and 
may cause irritation of the stomach and bowels. 

Buchu, cantharides, ergot, turpentine, creasote, lupulin, nitrate of 
potash, strychnine, and many other drugs have been used with little 
success. As a rule, it may be said, they fail where belladonna fails. 
Antipyrine has been said to give success, and lycopodium, in the form 
of tincture, has been extolled. 

The methods of painting the orifice of the urethra over with collo- 
dion, or of encircling the penis with plaster or an elastic band, hardly 
warrant further trial. 

Electricity has proved very useful in some cases, but its effects are 
transient. Picard applies one pole to the membranous part of the 
urethra in boys, and to the entire urethra in girls, and places the other 
pole on the hypogastrium, and records brilliant successes. 

Where belladonna and rhus fail, Sir Henry Thompson's method of 
freely cauterizing the urethra is almost sure to succeed. Before this is 
resorted to a sound or bougie may be passed, and this sometimes answers 
the same purpose; it may be passed daily for a week. When no im- 
provement results, a solution of nitrate of silver (10 grains to 1 ounce) 
should be injected by a catheter passed down to the prostatic portion 
of the urethra. In girls the solid nitrate of silver may be used to the 
urethra. In young women 3 grains of the salt, dissolved in 1 drachm 
of water, may be injected after the bladder is thoroughly emptied, and 
repeated in ten days again ; and good results have been obtained by 
Sims's method of dilating the bladder to its fullest extent by means of 
large injections of warm water. The injections are made by forcing 
in a stream of water through a catheter by means of the ordinary 
elastic enema apparatus, the treatment being kept up until 20 ounces 



INFLUENZA. 397 

of the liquid can be endured. The writer has had no experience of 
this treatment, and would be very slow to try it. 

Recently Gersuny has relieved incontinence by twisting the orifice 
of the urethra in the female. The passage of an ordinary sound at 
regular intervals has sometimes given good results. After the cessation 
of the incontinence, iron, arsenic, mix vomica, and other tonics may 
be given with, advantage, and very good results may be obtained by 
full doses of strychnine after a decided impression has been made by 
the administration of belladonna or atrophine, pushed to the extent of 
producing their physiological effect. 

INFLUENZA. 

Different epidemics vary so widely as regards the nature and degree 
of the symptoms that it is difficult to formulate rules applicable to 
future visitations of the malady. Thus, in the late epidemic which has 
passed over the greater part of the world, catarrhal symptoms were for 
the most part absent ; in former outbreaks catarrhal symptoms have 
been prominent, and this will, perhaps, in the future, be also true. 
There are, however, fixed features in every epidemic which indicate 
clear lines for rational treatment. Foremost among these is prostration. 
The late epidemic has afforded ample opportunities of studying this 
symptom, which was invariably the most prominent and the only fea- 
ture constantly present. This is not the place for the introduction of 
theories concerning the pathology or etiology of this wonderful epi- 
demic, nevertheless, the conclusions arrived at by the writer, after a 
most extensive experience of the outbreak, bear so directly upon treat- 
ment that they may be mentioned. It is highly probable that the 
disorder is caused by a microbe, and that the striking prostration is 
the result of the action upon the nerve centres and muscles of the 
poison which it manufactures during the brief period of its growth 
and development. The symptoms are not unlike what occur in diph- 
theritic paralysis, and the indication is the same — to promote elimina- 
tion and to keep up the strength of the patient from the very first with 
the most sustaining diet, as concentrated beef essences and nutritious 
soups, etc. The intense headache and pains in the back and limbs, 
even when there is not any fever present, should be relieved by mod- 
erate doses of antipyrine (15 grains), administered at the beginning of 
the attack, and half this quantity given every four hours, generally 
afford very speedy relief. The action of the drug upon the skin hastens 
the elimination of the poison and cuts short the course of the affection. 
The patient should be put to bed at once, and warm clothing and a 
little hot stimulant assist the action of the drug. 

Complications, such as pneumonia and bronchitis, are apt to be of a 
very asthenic type, and demand stimulating treatment, with brisk 
counter-irritation. Depressing expectorants, like antimony and squill, 
should be avoided, and pulmonary congestion, which often exists with- 
out passing into pneumonic consolidation, can be best met by full doses 



398 INGROWING TOE-NAIL. 

of quinine, in conjunction with teaspoonful doses of the aromatic spirit 
of ammonia, given mixed with a little whiskey or brandy, and well 
diluted with water. The following is a safe and efficient stimulant in 
such cases : 

R. — Ammonii carbonatis . . . . . . £iv. 

Tinct. cinchonse . . . ■ . . . ^ jss. 

Spt. ammon. aromat. . . . . . . " sjiv. 

Decocti cinchonse ad ^xij. — M. 

S. — One ounce to be taken during effervescence with half an ounce of lemon 
juice every four hours. 

Vomiting should be relieved by sinapisms on the stomach region and 
ice in small quantities, along with champagne. Hydrocyanic acid 
should not be given for this purpose, owing to the cardiac weakness 
generally present. 

Rheumatic symptoms, such as severe joint pains, if not relieved by 
the early doses of antipyrine, may be treated by 20 grains of the salicy- 
late of soda every four or six hours. 

Diarrhoea should not be interfered with unless it becomes excessive, 
when the dilute sulphuric acid (30 minims) may be given in combina- 
tion with tincture of opium (10 minims) after each loose motion. 
Should the motions still continue frequent and excessive, 10 grains of 
the extract of hsematoxylon may be ordered in combination with 1 
grain of opium. Acetate of lead or other astringent (see under Diar- 
rhoea, page 190) may be given. 

Alison had great success with tannic acid in doses of 30 grains three 
times a day. 

Food and stimulants in severe cases should be administered with 
regularity and persistence, and even rectal feeding may be required in 
very bad cases. It is of the utmost importance that the patient be 
seriously cautioned to remain in bed or in his room until convalescence 
is established. Many lives were sacrificed in the late epidemic by 
patients exposing themselves outdoors before the prostration had passed 
away, pneumonia being commonly the result. Isolation is supposed 
by some to be unnecessary, as the progress of the outbreaks generally 
proves that the disease is not carried from person to person as in ordi- 
nary epidemics of scarlatina, typhus, or smallpox. The writer, how- 
ever, satisfied himself thoroughly during the late epidemic that the 
pneumonia which followed the attack of influenza was distinctly infec- 
tious, and this complication or sequela should be treated by strict iso- 
lation. 

INGROWING TOE-NAIL. 

In mild or trivial cases the trimming or clipping square off the free 
margin of the nail, scraping of the dorsal surface with the edge of a 
bit of glass or with the knife, so as to reduce its thickness to produce a 



INGKOWING TOE-NAIL. 399 

tendency to curling upward or backward of its lateral margins, and the 
removal of any cuticle accumulated under the lateral edges of the nail, 
are all that are required to give relief and prevent further progress of 
the mischief. 

Pressure must be avoided in all cases, and the boot should be made 
sufficiently roomy, to prevent it pressing against the tender part, by 
having the inner margin of the sole so made as to end in a good square 
toe ; the modern fashionable tapering-toed boots are the cause of in- 
growing toe-nail in many instances. 

Where ulceration has occurred, a minute roll of lint shreddings should 
be neatly packed down between the tender overhanging skin and in- 
growing edge, so as to insinuate itself under this edge and cause eleva- 
tion of it. Strapping should be then applied, so as to retain the lint in 
this position and at the same time to drag upon the overhanging integu- 
ment and keep it pulled away from contact with the ingrowing edge. 
The lint may be removed at the end of a few days and the space filled 
with boric acid powder, iodoform, nitrate of lead, alum, oxide of zinc, 
or with the following powder : 

Be- — Pulv. iodoformi . . . . . . . giv. 

Calarninse prsep. gij. — M. 

S. — To be used as directed. 

Exuberant granulations may be destroyed with nitrate of silver, sul- 
phate of copper, strong solution of chloride of iron, pure carbolic acid, 
or acid nitrate of mercury. Sometimes repeated applications of these 
caustics may, at the same time, destroy the sharp ingrowing edge of 
the nail. 

Where caustics fail, cocaine having been applied freely, or the part 
being frozen with the ether spray, the overhanging granulations and 
integument may be shaved clean off by means of a sharp scalpel, and 
the wound left to heal under antiseptic dressings. This method, if skil- 
fully performed, often gives better and more lasting results than those 
following the operation of evulsion of the nail. 

There are decided improvements upon the old-fashioned method of 
inserting a roll of lint between the granulations and the under surface 
of the ingrowing nail. The best of these is carried out by using thin 
sheet lead instead of lint. A third layer of beaten-out silver also 
answers very well, but tinfoil is still better. It should be inserted 
under the edge of the nail, so as to thoroughly elevate it. This can 
rarely be accomplished at the first application, but in a few days the 
amount packed under the edge may be increased until the required 
elevation is accomplished. At the same time the foil may be gently 
packed in between the sharp edge and the overhanging granulations, 
the part dusted over with iodoform and enveloped in strips of plaster. 
It need not be changed for several days. This method, if carefully 
adopted and persisted in, generally removes the trouble. Where, 



400 INSANITY. 

however, it fails, and the nail is loosened by the ulceration involving a 
considerable portion of the surface of the matrix, there remains the 
operation of removal of the nail. This is easily accomplished, when 
the patient is fully under the influence of an anaesthetic, by inserting 
one blade of a pair of dressing forceps under the centre of the nail to 
its root and securing a firm grip as the blades are closed, and by firm 
traction the nail is removed. There is great temptation to pare or 
shave off a strip of the nail parallel to and including the ingrowing 
edge, but as a rule this does not lead to any permanent benefit. 

Sometimes one-half of the nail may be removed, after previously 
cutting it into two, by inserting one blade of a pair of fine and sharp- 
pointed scissors under its centre and pushing it down to the root. The 
loosened portion may then be easily removed by the forceps. Pow- 
dered boric acid being freely applied, the wound may be enveloped in 
lint moistened with alcohol and water, and surrounded with oiled silk. 

Cotting's method of treatment is radical and successful. It consists 
in removal with the knife of the diseased fleshy parts, together with a 
large and thick slice of the healthy and adjoining side of the toe. The 
cut should extend far back and be guided by the edge of the nail, 
which should be exposed but not injured by the incision. 

Hofmann has recently treated ingrowing toe-nail by pouring a few 
drops of a strong solution of ferric chloride upon the ulcerated spot, 
after elevation of the nail by means of bits of cork. The part is then 
permitted to dry, and the application repeated on the next and follow- 
ing day after. In a few days, upon removal of the resulting hard 
crust, the nail is found to be soft and friable, and easily removable with 
scissors. The writer has no experience of this method, which does not 
promise to supersede the older plans of treatment. 

More recently the following plan has been reported as most satisfac- 
tory by Piirckhauer ; it is bloodless and painless, and does not cause 
the patient to lie up. The nail is moistened with a warm 40 per cent, 
solution of caustic potash, and in a few seconds, as the surface becomes 
soft, it is scraped with a piece of glass, after which the solution is again 
applied and scraping repeated until the portion of nail to be removed 
is as thin as paper, when it can be lifted up with forceps and cut with 
scissors easily. 

INSANITY. 

To deal even in the briefest way with the treatment of the various 
forms of insanity is beyond the scope of the present work. Dementia, 
mania, melancholia, idiocy, moral mania, monomania, and their varie- 
ties, would require for a description of the necessary details of treat- 
ment space far beyond that at the disposal of the writer of the present 
volume. Moreover, these details can only be carried out in institutions 
specially designed for the purpose, and furnished with elaborate ma- 
chinery for insulating, watching, nursing, dieting, exercising, amusing, 
and instructing the victims of mental disorders. To undertake the care 



INSOMNIA. 401 

and management of insanity in the patient's home would be, in the vast 
majority of cases, a serious mistake, and a wrong to the patient, whose 
chances of recovery would be seriously diminished by such a pro- 
ceeding. 

The earliest possible removal to a suitable institution is of the utmost 
importance, and, as a rule, it may be said that in acute cases every 
day's delay diminishes to some extent the chance of permanent resto- 
ration. Where the patient's ailment is such as does not prevent his 
travelling and mixing with the public his early removal from home 
under the watchful care and close surveillance of a physician during a 
prolonged tour by rail or sea may be fairly tried with some hope of 
success before resorting to the restraints of an asylum. Such cases are, 
however, upon the whole rare where this method of treatment is avail- 
able or warrantable soon after the outbreak of an attack. 

The treatment of the various forms of insanity by drugs resolves 
itself into the judicious administration of remedies, with the view to 
correct the many deviations from the normal physiological state which 
may exist either as the cause or as the result of the abnormal state of 
the mind. Thus tonics for loss of appetite, and cod-liver oil, iron, and 
other restoratives are indicated when emaciation or anaemia exists. 
Narcotics should be avoided, except when pure hypnotics fail. 

Sleep should, speaking generally, be insured. The favorite drug is 
chloral ; but the writer, knowing its dangers when administered to sane 
patients, and having very little experience of it in insanity, hesitates 
to say anything in favor of it. Hyoscine has given excellent results 
in several large asylums, and the hypodermic injection of t ^q grain of - 
Merck's pure hyoscine generally produces the most desirable calm and 
sleep. Dr. W. E. Finny has recently used hyoscine by the mouth with 
success, in combination with digitalis, in chronic mania. (See author's 
work on Materia Medica, 5th edition, page 572.) Sulphonal may be 
also used. (See under Insomnia.) 

INSOMNIA. 

A concise description of the treatment of this condition presents 
great difficulties, owing to the innumerable causes upon which it may 
depend. An elaborate description dealing with the treatment of all 
these causes would fill a volume many times larger than the present 
handbook. Hence reference will only be made to the treatment of 
sleeplessness depending upon the causes most commonly met with. It 
is hardly necessary to say that in every case the first thing is to ascertain, 
if possible, the cause of the insomnia, and in many instances its removal 
will be followed by the disappearance of the sleeplessness. Thus the 
writer has known insomnia to depend upon a cup of strong tea taken 
late in the evening, and the patient not suspecting the cause continued 
to drink tea until the insomnia became alarming. 

Any sudden change in the hours of diet may be followed by insomnia ; 
thus some patients cannot sleep after a late supper, while others fail to 



402 INSOMNIA. 

get any sleep if they retire to rest with their stomachs empty. Sleep 
may only come to those who retire to bed immediately after wearying 
the brain, with active exercise. Others may be wholly unable to sleep 
if any previous mental activity has been indulged in. It is a very 
common experience to find among active brain workers that sleep- 
lessness follows after taking a day of rest and calm, and often the 
freedom from care and repose of the Sabbath results in the loss of 
sleep for the night. This is, of course, an unnatural condition, and 
deserves serious consideration. 

Mental anxiety, grief, exciting passions, dyspepsia, hepatic conges- 
tion, cardiac affections, many acute diseases, mania, insanity, delirium 
tremens, cerebral tumors, cold feet, and all conditions associated with 
pain, call not for treatment of the insomnia so much as for the relief 
of the above-named conditions which produce the insomnia. 

A very common error is to confine the management of the case to 
the administration of narcotics and hypnotics. These should never be 
employed except when simpler measures fail. Especially in chronic 
cases, the last thing which the physician resorts to should be a narcotic 
or so-called hypnotic. 

Regarding sleeplessness as the result of the transgression of some 
law of health, the patient's mode of life should be minutely examined 
with the view of finding out the transgression and remedying it. 
Unfortunately, the insomnia may remain for a considerable time after 
the cause has been removed. Wholesome diet, change of scene, a sea 
voyage, free open-air exercise near the sea if possible, and persisted in 
until fatigue is felt, the avoidance of all mental overwork, and as far as 
possible of anxiety and worry, should be advised. 

The writer has found that a long, smart walk just before bed-time is 
an excellent hypnotic, if the patient upon finishing it retires imme- 
diately to his room, undresses without sitting down, and goes to bed. 
Cold feet must be warmed and rubbed until tingling is produced. 
Robust patients can dip their feet for a few seconds into cold water, 
and restore the local circulation by having them rubbed briskly with 
a coarse towel. Feeble people must generally fall back upon the objec- 
tionable hot-water jar or India-rubber bottle. Cold water bandages 
to the forehead or scalp seldom do much good, and may keep the 
patient awake by causing discomfort locally. A hard bed is often 
better than feathers, and a hop pillow may have a good moral effect. 
Where the patient tolerates it, elevation of the head is a decided 
advantage, especially where there is want of vascular tone. There 
are some who fancy that they can sleep better w T hen their bed is placed 
due north and south. All sorts of devices are recommended for 
wearying the brain, such as counting up numbers, repeating verses, etc. 

The influences of monotonous noises or vibrations to which the patient 
has been long familiar, as the hum of city traffic, the sound of ma- 
chinery, of running water, etc., are often productive of good. The 
writer knew of an instance of protracted insomnia in the wife of a 



INSOMNIA. 403 

blacksmith, which after failure of all hypnotics and absolute stillness, 
yielded to the music caused by the loud hammering of an anvil in the 
forge beneath her bedroom. He has recently had an hospital patient 
who could not sleep until she got a small and rather noisy clock from 
her home and placed it by her bed-side. Thus perfect quietude is not 
always desirable. 

A copious warm drink or a cold water draught before lying down 
occasionally soothes some patients. The habit of reading oneself to 
slepp by the aid of some uninteresting author, though not to be recom- 
mended, is often efficacious. The absence of light is generally essential, 
and the morning sun should be shut out by blinds or shutters. 

Massage is a powerful hypnotic, and the writer has seen very wakeful 
and neurasthenic patients fall asleep during the performance of it. 
Sometimes, however, massage may excite. Eccles's plan is the best. 
He advises thorough rapid massage of the abdomen, thighs, and legs, 
so that a temporary anaemia of the brain may be produced by the 
blood flowing into the dilated vessels of the manipulated regions. A 
warm or hot compress to the abdomen tends to prolong the dilatation 
of the abdominal bloodvessels, and sound, refreshing sleep often 
supervenes. 

Hydropathy is a valuable aid in treating insomnia, and in some cases 
gives permanent relief. A warm bath should be taken until the patient 
is almost beginning to feel weak. He may then be enveloped in a 
flannel bath sheet, and when, lying on his bed upon the top of the bed- 
clothes his body should be perseveringly rubbed down by an attendant 
with a linen Turkish towel until a grateful sense of drowsy languor is 
felt, after which he should get under the bedclothes. The wet pack 
may be meployed for forty-five minutes wdth advantage, but it will be 
better to use a sheet wrung out of tepid or warm instead of cold water, 
as generally recommended. Friction with a rough w T arm towel should 
be afterwards employed, and the amount of over-clothing should not 
be such as to encourage profuse perspiration which may keep the 
patient awake. The local pack to the trunk may likewise be employed 
with advantage, and after getting to bed its good effects may be kept 
up by giving warm or hot drinks. 

The cold douche has been recommended, and is valuable in allaying 
the cardiac excitement upon which the insomnia may depend. 

Gel 1 horn uses a piece of calico, eighteen inches wide and nearly three 
yards long, rolled up like a bandage, and a third of it wrung out of cold 
water. With this he bandages the leg, the wet portion being carefully 
covered up by several layers of the dry part as well as by a layer of 
gutta-percha tissue, and a stocking drawn over the whole, the dilata- 
tion of the vessels which follows diminishes the amount of cerebral 
blood and induces sleep, especially where there is any cerebral con- 
gestion. 

Electricity has in many cases given excellent results ; it may be used 
in many ways. The writer employs a weak constant current of three or 



404 INSOMNIA. 

five cells of a Leclanche battery, with one electrode on the forehead, and 
the other on the occiput for five, ten, or fifteen minutes. The inter- 
rupted current to the spine, alone or in conjunction with massage, has 
been used in some cases with satisfaction. 

The best results, however, are obtained from static electricity. After 
insulation of the patient upon a glass stool, his body is brought into 
connection with the conductor of a Carre or Holtz machine, and when 
thoroughly electrified a fine metal point is held opposite several spots 
on the scalp and forehead not near enough to produce a spark. The 
sensation is as if a light wind or breeze was pleasantly playing over 
the region, and McClure has found sleep come on while this form of 
electric souffle was being employed. The production of heavy sparks 
is not necessary or advisable, but the use of the metal cap and static 
insulation gives the best results which can be obtained from electricity. 

Where the above-mentioned remedies fail, the physician then feels 
himself driven to employ drugs of the narcotic or pure hypnotic class. 
The fear of creating a habit which may enslave the patient for life 
should always be kept before the mind of the physician, especially in 
cases where the condition has lasted for a long time. In dealing with 
insomnia of short duration, this is not at all a probable danger. 

Of all the drugs ever used to counteract sleeplessness, there is not, 
on the whole, one so generally valuable as alcohol in some form or 
other. As remarked elsewhere by the writer, the various spirituous 
beverages have very different therapeutic actions, which cannot be 
explained by their alcoholic strengths. Thus for insomnia the various 
wines are inferior to whiskey, and brandy does not produce as good 
results as whiskey. Strong ale is highly hypnotic, and so is porter or 
stout. To obtain the best hypnotic effect from alcohol, it should be 
given in one full dose just as the patient has undressed and lain down 
in bed. It acts more certainly if given warm, but not hot. One wine- 
glassful (2i fluid ounces) of good whiskey, made into warm punch, 
and swallowed as a draught — not sipped in spoonfuls — is a most 
invaluable soporific. Where the physician has reason to dread the 
formation of the alcohol habit, it may be mixed with a bitter, or may 
be forbidden altogether after a short time ; but the writer has not met 
with an instance where the patient has so suffered when the drug has 
been given with the above-named restrictions. The danger of intem- 
perance is much greater when alcohol is ordered in smaller quantities 
to be taken with meals. 

It is, moreover, surprising to notice, when the patient abstains from 
the use of alcohol at all other times, how the same dose may continue 
to produce its beneficial hypnotic effects without requiring augmenta- 
tion for very long periods. Headache and malaise seldom follow, and 
when they do, they may be prevented by using a purer whiskey of 
greater age. 

The product of the patent or silent still should be condemned. 
The amylic alcohol which it contains, though very small in amount, 



INSOMNIA. 405 

does not mellow, or split up into the various ethers which develop 
during the progress of time in the liquid produced by the old pot-still. 

"With few exceptions, the drugs employed to produce sleep up until a 
comparatively recent date were selected from the group of narcotics, 
nearly every member of the group being more or less used for this 
purpose. The introduction of the pure hypnotics, whose properties 
will be mentioned later on, has marked an era in therapeutics. Never- 
theless, narcotics must ever hold a high place, being invaluable in 
many forms of insomnia, where the pure hypnotics are useless. 

Opium is the most prized member of the group, and its superiority 
over the new hypnotics lies in its power of relieving pain and distress. 
As a rule, it may be said that the new hypnotics have no influence 
over pain, and until it is relieved their action fails to induce sleep. 

Opium possesses the power of relieving pain by preventing the con- 
duction or perception of painful impressions, and sometimes this can be 
done by employing doses so small as to have no soporific effect what- 
ever. As sleeplessness is so very often caused by pain in the innumer- 
able instances of diseased action coming constantly under the notice of 
the physician, it must be used often to induce sleep, as in neuralgia, 
sciatica, pleurisy, cancer, angina, etc. In simple chronic insomnia, 
whether produced by mental over-work or occurring in the insane, and 
when not caused by or complicated with pain, opium or its alkaloids 
should not, as a rule, be employed. 

As the present article deals chiefly with such simple insomnia, little 
space need be given to the discussion of narcotics. The danger of 
inducing the opium or morphine habit is so great in chronic insomnia 
that the indications for these remedies should be strong indeed to tempt 
the physician to prescribe them. Where the insomnia is of very short 
duration, and caused by mental worry or over work, which is not at all 
likely to be repeated or become a habit — in short, where the cause is 
fleeting, or has already fled — opium is an invaluable hypnotic, and 
may be employed in such a case with great advantage. The dose 
should be a full one, H or 2 grains of opium, or 30 minims of the 
solution of morphine (1 : 100). The dose should be given as the 
patient lies down, and darkness and quiet should be maintained. If 
sleep does not result in two, three, or four hours, the same quantity 
may be again administered. 

When morphine is administered hypodermically as a hypnotic for 
the first time, a dose of alcohol should be given a few minutes before 
it, or 1 minim of solution of atropine (1 : 100) should be injected 
along with it. When pain is present, larger doses of opium or mor- 
phine are required, and it is, as a rule, better in such cases to repeat 
the dose at a shorter interval than to give one very large dose. In 
chronic bronchitis with profuse secretion, in the late stage of phthisis, 
in congested states of the brain with contracted pupils, and in all the 
ailments of childhood or infancy, opium is contra-indicated. 

In the insomnia of delirium tremens opium or morphine may be 
given in large doses. (See page 167.) 



406 INSOMNIA. 

In the painiul insomnia of cardiac distress, hypodermic injections of 
morphine (i grain) often give great relief and sound sleep when every 
other hypnotic has failed. 

In acute melancholia or mania, morphine is still employed, but the 
newer hypnotics are generally far better. Codeine, narceine, and 
bimeconate of morphine, and the various preparations of opium, as 
black drop, Battley's sedative, nepenthe, etc., may be tried where the 
after ill consequences of opium have been barriers to its use. Codeine 
is a very feeble hypnotic. Opium or morphine may be combined with 
most of the new hypnotics, and the writer has often relieved pain with 
small doses of morphine, and afterward induced sleep by 20 grains of 
sulphonal. The dose, even when the minor action of morphine only is 
required, will generally need augmentation, and this is one of the chief 
objections to to the use of opiates in insomnia and all chronic condi- 
tions associated with sleeplessness. 

Meco-narceine is the name given by Laborde to a new hypnotic alka- 
loid obtained from opium, which is said to produce no headache or 
gastric disturbance. 

Cannabis indica is open to nearly all the objections to which opium 
is liable, and hence it is not a suitable drug in the treatment of 
simple chronic insomnia. It does not, however, exert such deleterious 
influence over digestion, nor does headache so frequently accompany 
its administration even in large doses. Cannabin tannate is an excel- 
lent form for prescribing the drug in doses of 5 grains in the insomnia 
of mania. 

Hyoscyamus has been long used as an hypnotic. It is but seldom 
employed now, unless in combination with bromides. 

Hyoscine, which is the amorphous alkaloid obtained from hyoscyamus, 
and which forms crystallizable salts, is one of the most valuable of the 
hypnotics which have been recently introduced. It is now obtainable 
in such purity that a dose of t ^q grain administered hypodermically is 
a powerful soporific. The hydrochlorate or hydrobromate, as prepared 
by Merck, is the most trustworthy preparation. In acute mania and 
other conditions of grave excitement with motor disturbance, it is the 
most rapid and certain hypnotic known. 

According to Krauss, after its administration the maniac collapses 
as if struck by lightning, but the calming down of the general paralytic 
is gradual, his restlessness soon settling down into peaceful slumber. 
The drug is not without its drawbacks, and though many observers 
assert that it has no influence upon the heart, nevertheless it is apparent 
that a remedy of such potency is not one to be employed in a routine 
way in the treatment of simple chronic insomnia. Some authorities 
have reported sharp, depressant effects from -^ grain, and it will be 
wise to regard valvular disease as a contra-indication to its use. In 
insomnia associated with or depending upon a latent strain of insanity, 
hyoscine is the most reliable weapon in our armory. Webber gives 
the drug by the mouth, and the following formula may be employed 
in insomnia : 



INSOMNIA. 407 

R. — Hyoscin. hydrobrom. (Merck) . . . . gr. h. 

Tinct. aurantii amar ^j. 

Aquredest ^iij. — M. 

S. — One measured drachm to be taken at bed-time. 

This dose of g 1 -^ grain of the hydrobromate by the mouth should not 
be exceeded at first. The best results have been uniformly obtained 
by the hypodermic injection of y^-g- grain of the hydrochlorate. The 
dose may afterward be increased to -g 1 ^ grain. Deep, quiet sleep gener- 
ally follows in twenty minutes, and lasts for six or eight hours without 
any after ill consequences. 

Hyoscyamine is still occasionally used. It may be given in larger 
doses (Jq- grain) than hyoscine, to which, as an hypnotic, it is inferior. 
(See Materia Medica and Therapeutics, fifth edition, page 572.) 

Bromides of potassium and sodium are certainly the least harmful of 
hypnotics. In mild cases of insomnia following prolonged mental 
activity and overwork, full doses (30 to 40 grains) of the potassium 
salt produce calm, deep, and refreshing sleep. In severe cases it very 
often fails, but failure does not leave the patient in a worse condition 
than if he had not taken the drug. The cases where its best effects 
are uniformly observed are those where sleeplessness is caused by over- 
mental activity — a state not of simple wakefulness, but where the brain 
is unusually active, and the mind excited by a rapid succession of bril- 
liant ideas. This condition often supervenes upon the patient retiring 
to rest immediately after some mental effort or worry, without permit- 
ting a period of rest, during which the mental faculties should have 
been diverted into other channels. In this state there is some flushing 
of the face, and throbbing of the carotids and pulsations are felt in the 
cranium. The brain feels like an active galvanic battery, and new 
thoughts arise in rapid succession, and the patient feels a capacity for 
mental work to which he was unequal in the hours of the day. This 
is a very frequent occurrence in public speakers and debaters. If 30 
grains of bromide produce no effect in an hour under these circum- 
stances, the dose may be repeated, and if sleep does not soon follow, a 
full dose of warm whiskey punch will rapidly produce sound slumber. 
There is a state of restlessness of a totally different sort often observ- 
able in highly nervous patients after getting into bed, in which the 
slightest external stimuli call forth incessant and ineffectual attempts 
to dispose the limbs, head, or trunk in such positions as will give a 
sensation of comfort and tranquility. This, which might be called 
" acute fidgets," is controlled effectually by a few doses of the bro- 
mides, which probably act by diminishing reflex excitability. 

The bromides may be taken for long periods without hurt. In one 
patient with a bad family history of insanity who suffered from insomnia, 
the bromide of potassium, combined with a small dose of tincture of 
hyoscyamus (20 minims), was steadily taken almost every night for 



408 INSOMNIA. 

twenty-five years with most satisfactory results, and with no necessity 
for augmentation of the dose, and with no ill consequences. 

Chloral has been extensively employed as an hypnotic in simple 
insomnia and delirium tremens. It is, perhaps, the most certain 
soporific which we possess when pain is not present. It is open, 
however, to two serious objections which probably will ultimately lead 
to its disuse as a therapeutic agent. These are the dangers of estab- 
lishing a chloral habit, and the depressing influence which the drug 
exerts upon the heart. It directly affects the cardiac muscles, dilates 
the arterioles, and may injuriously affect respiration.. These effects 
have frequently followed the medicinal doses still believed by many to 
be safe, and death has resulted. Generally sleep is profound and 
refreshing, and the after ill consequences are trivial. It acts rapidly, 
and the slumber may be prolonged to ten or twelve hours. Its depres- 
sant action should distinctly forbid its use in cardiac disease, in 
emphysema, and bronchitis, and in the late stages of typhus and 
typhoid insomnia, when the cardiac muscle is always weakened. 

In mania and in the sleeplessness of the various varieties of insanity, 
its soporific virtues are so uniformly experienced that there is a great 
temptation to employ it in a routine fashion. Though many patients 
have taken it without any ill effects in these diseased conditions for 
many months, there is always a remote possibility of a lethal action 
upon the heart.' This is especially liable to ensue when the dose has 
been increased, and the fact of its having been previously taken with 
great advantage is no safeguard against its depressant cardiac action 
upon some future occasion. 

It acts rapidly, and should be given immediately before retiring to 
rest, and as some patients are very susceptible to its influence, it is wise 
never to begin with a larger dose than 20 grains. 

It has been combined with morphine or bromides with advantage, 
and the writer believes that one or two ounces of whiskey given at the 
same time greatly increase its efficacy and materially diminish its power 
of depressing the heart. Some authorities strongly condemn the com- 
bination of chloral and morphine as the most dangerous of hypnotics. 
The writer cannot confirm this important judgment, as he so seldom 
gives the drug in insomnia, but it is worth being noted. The value of 
the bromides when given with chloral is above dispute, as a smaller 
dose suffices. 

The following combination may be tried : 



K.— Chloral . 

Potassii bromidi 
Tinct. opii 
Syr. aurantii flor. 
Aquae dest. 
S. — The half to be taken at bed- 
ward, if necessary. 



gr. sxx. 
gr. xxxv. 

. TTL xxx. 

Z i y - 
. ad ^iij— M. 

ime, and the remainder in three hours after- 



INSOMNIA. 409 

Butyl-chloral hydrate possesses many of the good qualities of chloral, 
and is less dangerous. It is, however, a decidedly weaker hypnotic 
unless where sleeplessness is caused by some painful condition of the 
fifth nerve. It is in these latter instances that it is generally employed, 
and as a pure hypnotic it has not met with a success warranting its 
administration, except where the more trustworthy agents have failed. 

Chloral-urethane or ural is a new hypnotic obtained from chloral by 
precipitating a solution of urethane in chloral by adding hydrochloric 
acid. It is claimed for it that the urethane counteracts the depressant 
cardiac action of the chloral It produces deep sleep ; but sufficient 
corroboration of the high praises bestowed upon it by Poppi has not 
yet been forthcoming. One effect reported does not auger well for its 
future use — it has been observed to lower the blood-pressure. 

Somnal is the name given to ethylated chloral-urethane, which in 
30 grain doses acts like chloral, and it is said to be free from its serious 
drawbacks. 

Chloralamide is another new hypnotic prepared by combining chloral 
with formamide. It promises well, though the reports are still too few 
to base any strong conclusions upon. It is in the form of small color- 
less, odorless, slightly bitter crystals, soluble in water. Thirty to 45 
grains is the dose most frequently employed, and it may be adminis- 
tered by the rectum without causing irritation. 

Sleep comes on in less than one hour. It seems somewhat less 
powerfully hypnotic than chloral ; but there is no dilatation of the 
arterioles or fall of blood-pressure, and as yet no depressant influence 
over the heart and respiration has been noticed. Like chloral, it 
would appear to possess some very feeble pain-relieving properties. It 
is indicated in the same class of cases as chloral and in simple insomnia. 
If it be found to be free from the seductive influence of establishing a 
habit like its ally, it will be a valuable addition to therapeutics. It 
has already been used as an hypnotic in heart diseases and bronchial 
affections ; its hypnotic power is roughly calculated at two-thirds of 
chloral hydrate. 

Chloralimide is the name given to a still newer hypnotic, which 
differs chemically from chloralamide. It is said to be more active than 
that substance, and more pleasant to take, and free from the objections 
of chloral hydrate ; but it is still upon its trial, and we know practi- 
cally nothing of its alleged innocence. 

Sulphonal has been one of the most valuable of the many recent 
additions to therapeutics. It is a colorless, odorless, tasteless, insoluble 
salt, and may be given in doses of from 15 to 60 grains. It is the type 
of a pure hypnotic, and possesses no analgesic properties. In small 
doses it possesses the remarkable power of checking or preventing the 
night-sweats of phthisis. 

In cases of simple insomnia uncomplicated with pain it acts with 
much certainty, and is altogether free from the objectionable qualities 
possessed by chloral. Thus experience has proved that no sulphonal 



410 INSOMNIA. 

habit has been observed, and though it appears to have slight and insig- 
nificant cumulative action, there is no necessity for increasing the dose. 
Sleep does not come on immediately, sulphonal being very slow in its 
action, and sometimes three or four hours elapse before the soporific 
effect begins to manifest itself. The duration of its action is about that 
of chloral — six to eight hours. Professor Leech has drawn attention 
to the prolonged deferred action of sulphonal, which sometimes causes 
a drowsiness, which may last for a considerable part of the day follow- 
ing its administration. This is more liable to happen when it has 
failed to induce sound refreshing sleep after the usual interval. It has 
been very often noticed that this drowsiness extends into the following 
night, and some patients who use the drug constantly, find that it pro- 
duces better effects upon the second night without taking any more of 
the drug in the meantime. Hence the writer has adopted the practice 
of only giving sulphonal in full doses every alternate night in simple 
insomnia. There is no depressant cardiac action, and the respiration 
and arterioles are not influenced. The only untoward effects worth 
mentioning are those which occasionally have been observed in the 
nervous system. Restlessness, hallucinations, vertigo, giddiness, and 
confusion of thought, have sometimes, though rarely, been noticed to 
take the place of sleep. 

Ataxia with staggering gait has been several times noticed, and after 
full doses the incoordination has appeared to resemble drunkenness. 
In one highly nervous patient afflicted with severe insomnia the writer 
was informed that most miserable depression followed its administra- 
tion ; but this was in a subject in whom almost every known hypnotic 
had produced unpleasant or alarming symptoms. 

These after-effects of sulphonal have not been known to lead further 
than to unpleasantness, and the innumerable host of reports which have 
appeared during the past few years seem to justify the hope expressed 
by the writer in 1888 that "the days of chloral hydrate are num- 
bered." 

Thirty grains partially dissolved in a little warm beef-tea or hot 
water should be given about an hour before retiring to rest. If a 
moderate dose of whiskey punch be substituted for the hot water the 
most unobjectionable and certain hypnotic combination will be obtained. 
When the alcohol is combined with it, the dose should be given as the 
patient retires to bed. 

The writer has noticed that when dissolved in hot punch its effects 
are much more rapid; and recently a writer in one of the journals has 
pointed out that if dissolved in boiling water it will not fall down as 
cooling occurs. This is a valuable contribution, as the insolubility of 
the drug is its only drawback. The writer generally gives it in fine 
powder, made up as a sandwich between two pieces of thin bread and 
butter, and owing to the insolubility of it in this form, it should be 
given two or three hours before bed-time. If dissolved in boiling water 
it may be given upon lying down. 



INSOMNIA. 411 

From the above remarks it will be noticed that the range of sulphonal 
is most extensive. It may be given in the sleeplessness of every disease 
where pain is absent, and it is, upon the whole, the best remedy for 
simple insomnia. In insanity, however, it is inferior to paraldehyde 
and hyosciue, in the opinion of those best calculated to judge, and in 
all depressed states of the mind its action is less certain. Sixty grains 
appear to be about equal to half a grain of morphine in hypnotic effect. 
It is the best soporific for children. 

Paraldehyde is a pure hypnotic of great value. It may be regarded 
as practically free from danger and after ill-effects. Its most objec- 
tionable taste and odor are its greatest disadvantages. It may be given 
in drachm doses for weeks or months at a time, and the dose, as a rule, 
does not need to be increased. A paraldehyde habit has been observed 
to follow it habitual use in a few cases. It is indicated in every form 
of sleeplessness where pain is absent, and is the most reliably hypnotic 
in cardiac cases. In pulmonary distress it is inferior to sulphonal. In 
insanity, paraldehyde has undoubtedly given better results than any 
other drug, and its new rival, sulphonal, has been compelled to give 
way before it in the routine treatment of the insomnia of acute mania 
melancholia, and general paralysis. This is chiefly owing to the fact 
that the unpleasant nervous symptoms following sulphonal have de- 
terred physicians pressing its administration in doses very much larger 
than the avery dose of 45 or 60 grains, while paraldehyde can be fear- 
lessly given in doses of 4 to 6 or more drachms. Thus, Clouston has 
given it for a fortnight to a general paralytic in doses of 4 drachms. 

It acts with rapidity, sleep lasting about six hours, and there are 
very little unpleasant sensations next day save the most disagreeable 
odor which it imparts to the breath. This is so obvious to those com- 
ing in contact with the patient, that it prevents its general use in simple 
insomnia. It may be given with mucilage or brandy. 

R. — Paraldehyde 3J. 

Mucilag. acacias sjij. 

Syr. simplicis ^ij. 

Aqu?e cinnamomi 3 x j- — M. 

S. — The draught to be taken at bed-time, after shaking the bottle. 

Capsules and suppositories have also been used. 

Urethane has been much used as a perfectly safe hypnotic, and has 
been recently praised by Leech and Gordon as a remedy for mild cases 
of insomnia. The writer, like many others, has ceased to employ it 
owing to its uncertainty. Even in doses of 100 grains it very often 
produces no appreciable hypnotic effect. If we had no other harmless 
hypnotic it might still be urged that it should have further trial, but 
there is no reason why it should not be permitted to fall into disuse. 
It has been recommended to give it in combination with chloral, but 
chloral-urethane meets this suggestion thoroughly. 



412 INSOMNIA. 

Hypnone is also a most unreliable hypnotic, and the same verdict 
may be safely pronounced upon its employment in insomnia, though 
sometimes it does seem to produce sound sleep. It has a most objec- 
tionable odor and taste. It causes so much gastric irritation that it 
cannot with safety be given, even in the form of capsules (4 minims), 
without producing pain or vomiting. 

Acetal, owing to its uncertainty of action and its objectionable taste 
and odor, seems also unworthy of a place in the list of remedies for 
insomnia. Its dose is about 2 drachms. 

Methylal, first introduced by Richardson, is a strongly smelling 
liquid, causing sleep in doses of about 3 drachms. It is very expensive. 
It is a weak hypnotic, and very often fails. Its sweet taste and rather 
agreeable odor contrasts favorably with these physical properties of the 
last-mentioned members of the hypnotic group. It is needless to say 
that as an hypnotic it will cease to be tried, as it has never had the 
chance of coming into general use, owing to its expensiveness. 

Amylene hydrate is a colorless tertiary alcohol, which has been found 
to produce reliable hypnotic effects in doses of about 1 drachm. It is 
best given in claret or any weak wine, and it appears to act like chloral, 
without exerting dangerous depressant action upon the heart in ordi- 
nary doses. It acts very rapidly, but its unpleasant taste and expen- 
siveness are barriers to its usefulness, though it has been found to give 
effects equal to those of paraldehyde in delirium tremens and melan- 
cholia. It can be, moreover, safely given to children. 

Antipyrine and antifebrin have been credited with hypnotic influence, 
but where this has followed their administration, it has been probably 
brought about by their valuable analgesic action, sleep following natu- 
rally after pain was removed. 

Chloroform and ether have been used with benefit in exceptional 
cases of severe insomnia, which resisted other hypnotics, but their use 
cannot be recommended, and obviously cannot be continued or kept 
up, even in the most exceptional cases. Ether may be tried in full 
doses by the mouth where other remedies fail. It is, however, uncer- 
tain as an hypnotic, and is liable to produce the ether habit, as seen 
in the cases of ether tipplers common in some parts of the North of 
Ireland. 

Sumbul, musk, camphor, boldo-glucine, lupulin, lettuce, and many 
other drugs have been used from time to time with little success. 
When the previously mentioned hypnotics fail, these latter are useless. 
Digitalis sometimes helps sleeplessness by improving the tone of the 
cerebral arteries. 

Hypnotism has been recently tried with success for insomnia, and 
great interest attaches itself to the future trials of this mysterious agent. 
There are cases of inveterate insomnia in the sane, which are occasion- 
ally to be met with, and which resist treatment by all hypnotics, owing 
to the failure of the drugs to induce sleep, or owing to the terrible de- 
pression following their action. Static electricity, massage, and the 



INTERMITTENT FEVER. 413 

other means enumerated at the commencement of the present article, if 
tried unsuccessfully, leave nothing but this last-mentioned agent as a 
last resource. In such cases, if hypnotism succeed even in giving tem- 
porary relief, an immense gain to therapeutics will result. 

INTERMITTENT FEVER. 

The treatment for this disease might be summed up in the word — 
quinine. Where the therapeutist wishes to point to an example of a 
" specific," he generally finds that the action of quinine in ague leaps 
at once into his view. When the first symptoms of an attack show 
themselves, at the very beginning of the cold stage, the important 
question arises: Can this attack be cut short? Most authorities are 
satisfied that it cannot, and that, no matter what remedies be used, the 
disease must take its course, and pass through the cold, hot, and 
sweating stages. 

Nevertheless, there is abundant evidence that the attack may be 
very materially mitigated or modified in some cases by the prompt 
employment of remedial agents. 

The patient should immediately be put to bed, and hot water bottles 
and warm clothing freely supplied. Hot drinks or warmed stimulants 
are useful. Nitrite of amyl and other nitrites very often stop the chill 
promptly, but do not appear to influence the succeeding stages. Pilo- 
carpine in a full dose (i to J grain), administered hypodermically at 
the first onset of the symptoms, has been found in some cases to cause 
abortion of the attack. To be of any use, however, it must be given 
at the very commencement of the seizure. Atropine has been also 
used, but is not reliable. Chloroform, internally, in one full dose (20 
to 40 minims), or one large dose of opium, has been also found to 
diminish the duration and intensity of the attack. 

Bleeding, purging, blistering, cupping, and emetics, have also been 
found useful, but are now seldom employed. Moderate purgation 
should generally be prescribed, as it undoubtedly increases the efficacy 
of the remedies to be afterward given in the latter stages. 

When the hot stage sets in, considerable relief may be obtained by 
removal of the extra clothing and the free sponging of the skin with 
cold or tepid water. Cold compresses are grateful. It does not appear 
that the new antipyretics have been of much use in this stage of the 
paroxysm. 

In the sweating stage, gentle friction with hot towels and changes of 
underclothing may give some relief. After this stage is over, the 
patient may be permitted to get up and move about. 

While there may be considerable difference of opinion regarding the 
utility of many of the above means being used with the view of abort- 
ing or modifying the early stage of the paroxysm, there cannot be a 
second opinion about the urgent necessity of prompt treatment for 
preventing the recurrence of the attack. All experience points to the 
conclusion that the subsequent difficulties are very greatly increased 



414 INTERMITTENT FEVER. 

when the treatment of intermittent fever has in the first instance been 
neglected. 

As already mentioned, quinine is a specific for this disorder, and by 
a consensus of opinion it is maintained that to best prevent the parox- 
ysms recurring, this drug should be given as soon as possible after the 
urgent symptoms of the seizure have passed off. Most authorities 
prefer not to wait until the symptoms of the paroxysm have actually 
subsided, but they advise that it should be given during the sweating 
stage. Ten grains should, therefore, be given in solution or in pills 
toward the termination of sweating stage, and 5 grains. every four 
hours for three doses afterward, by which time the physiological effects 
of the drug will probably be manifested. 

Rarely will larger quantities be required. It is a mistake to give 
large doses during the cold or hot stages. When vomiting is a promi- 
nent symptom there may be a difficulty in administering quinine by 
the mouth, in which case 20 grains can be given in the form of an 
enema. There is considerable difficulty in introducing the drug into 
the system by hypodermic injection. In the period of time, extending 
from the beginning of one attack to the beginning of the next attack 
(i. e., the interval), about 20 grains is a fair average amount of quinine 
in ordinary quotidian ague. In malignant or pernicious intermittent 
fever 25 or 30 grains of may be given at once, and 10 grains in four 
or six hours afterward. The neutral sulphate in solution in warm 
water, or quinine dissolved in ether, should be injected when the 
stomach and rectum fail to retain, and in these malignant cases this 
remedy must be pushed at all hazards. 

All the cinchona alkaloids are of value in ague, and the sulphates 
of quinine and quinidine being the most active are to be preferred to 
cinchona in powder, which owing to its bulkiness is apt to cause gastric 
disturbances. 

The administration of the remedy should be pushed until there is 
conclusive evidence " that the paroxysms are broken." Afterward it 
should be continued in smaller daily doses for some months, until long 
after the thermometer and the absence of periodical increase of urinary 
salts have proved that the disease has disappeared. Upon the least 
sign of a return, it will be advisable to resume the administration of 
the drug in doses sufficient to produce cinchonism. 

Though hosts of ague specifics have been recommended, it is rarely 
necessary to resort to any drug but quinine, which in the great majority 
of cases cut short the disease with rapidity and certainty. In malig- 
nant cases one is not justified in trusting to any other agent as time is 
an important element in the case, and death may supervene before any 
other remedy has time to act. Among the drugs found to possess 
marked antiperiodic powers next to quinine stands arsenic. It is some- 
times found to cure when quinine has failed, and this is especially true 
if the ague is of the quartan type, or if it has been of long standing. 
Five minims of Fowler's solution may be given three times a day. It 



INTERTRIGO — INTESTINAL OBSTRUCTION. 415 

may be combined with quinine in the treatment of the malarial 
cachexia. 

Decoction of fresh un peeled lemons has been proved to possess valu- 
able anti-malarial properties, and may be given freely, alone, or in 
conjunction with quinine. 

Salicin, beberine sulphate, apiol (20 minims), narcotine (1 grain), 
camphor, capsicum, grindelia, hydrastis, eucalyptus, Prussian blue (90 
grain doses), chloride of sodium (1 ounce doses), nitre (15 grains), 
sulphites (2 drachm doses), chloride of ammonium (2 drachms), 
piperine, ergotine, iodide of potassium, bromides, nitric acid, iodine 
(free), phosphorus, strychnine, quassia (in large doses), resorcin, and 
about as many more drugs have been from time to time expected to 
share the success of quinine — they are seldom used. 

Warburg's tincture possesses powerful diaphoretic and antiperiodic 
properties, and is highly praised by Maclean. (See author's Manual of 
Materia Medica and Therapeutics, 5th edition, page 620.) 

Quinine possesses also great prophylactic power, and 5 or 8 grains 
daily will generally be found to afford protection in bad malarious 
districts. 

The after consequences of ague or the malarial cachexia will be best 
treated by removal from the malarious district, and the steady admin- 
istration of quinine, arsenic, and iron. Maclean strongly recommends 
a sea voyage, and a sojourn at the baths of Carlsbad or Homburg. 
The enlarged spleen gives way to large doses of quinine and iodide of 
potassium, and to local applications of biniodide of mercury ointment, 
or of lin. potass, iod. cum sapone, B. P. 

INTERTRIGO 

The treatment applicable to acute eczema (page 226) will speedily 
remedy this affection. As it occurs about the flexures of joints, or 
where overhanging or overlapping folds of integument are permitted 
to remain in contact, it will generally be necessary to separate the 
opposing surfaces by a fold of lint or absorbent wool smeared over 
with zinc ointment, or freely sprinkled with Fuller's earth, zinc oxide, 
bismuth subcarbonate, or other drying powder, to which a little finely 
pulverized camphor has been added. As a rule, pastes, powders, or 
stiff ointments are very much better than lotions. The following is a 
good ointment : 

&. — Unguent, zinci oxidi ^ij. 

Bismuthi subcarb. ^ij. 

Calaminse praep gij. 

Spt. camphorse ^j. — M. 

S. — To be used as directed. 

INTESTINAL OBSTRUCTION. 

No more serious problem can be presented to the mind of the physi- 
cian than that involved in the treatment of a case of acute intestinal 



416 INTESTINAL OBSTRUCTION. 

obstruction. Year by year operative measures are becoming more 
generally recognized as an early indication instead of being regarded 
in the light of a dernier ressort, as has been the case in the past. 
Already there are not wanting signs that the pendulum has swung too 
far in this direction, some authorities recommending an immediate 
resort to laparotomy without waiting for any trial of the older thera- 
peutic agents. The natural tendency, doubtless, is to wait too long 
before resorting to abdominal section, and hence it is perhaps an advan- 
tage that the earliest adoption of operative measures should be put in 
the most forcible light possible. The natural reluctance to such a 
serious undertaking will probably always prevent the operation being 
performed before opium, enemata, etc., have obtained a trial, though 
these measures probably will cease to be pushed so far to render 
operative interference too late. 

The first step in arriving at a conclusion regarding the best treat- 
ment is to make as accurate a diagnosis of the cause of the obstruction 
as the difficult unravelling of the tangled web of the symptoms will 
permit. In those cases where a positive diagnosis is possible, the diffi- 
culty of deciding upon the most appropriate treatment is not great. 
No decision for or against operation should be arrived at until the 
physician has exhausted every means of coming to a conclusion as to 
the case being one of volvulus, intussusception, strangulation by bands 
or apertures, etc., stricture, fecal accumulations, or tumors. Unfortu- 
nately it is not within the scope of the present volume to discuss the 
various symptoms which enable the physician or surgeon to differentiate 
these various causes of intestinal obstruction. 

In the great majority of cases it is impossible to arrive at any con- 
clusion until the symptoms have been watched for a short time ; indeed, 
it is impossible to be certain that the case is one of obstruction until a 
certain time has passed over. During this period the lines of treat- 
ment are clear. Absolute rest in the horizontal position in bed with 
the knees drawn up as the patient lies upon his back is the easiest posi- 
tion, and the one naturally assumed during the later stages. As vomit- 
ing is an early symptom, little nourishment can be retained, and efforts 
at forcing it into the stomach are worse than useless. 

Frozen milk would be the best possible dietary under such circum- 
stances, but it is seldom convenient. Small pieces of ice frequently 
sucked or swallowed, and an occasional teaspoonful of Brand's beef 
jelly, is the most that should be attempted. 

Opium is of the greatest service, and is to"%e given in proportion to 
the amount of pain present. There is, however, one serious objection 
to it, but which, nevertheless, cannot be permitted to forbid its use — 
i. e. y it tends to mask the symptoms, and may mislead. The experienced 
physician will constantly have to make allowance for this, and have it 
ever before his mind in weighing the serious issues as the case advances. 
The opium should be given as the case may indicate. Thus in violent, 
sudden pain, soon followed by vomiting, the hypodermic injection of 



INTESTINAL OBSTRUCTION. 417 

h grain of morphine, or an euenia containing 45 minims of laudanum, 
should be given. As a rule, solid opium, or the powdered preparation 
made into pills, should not be administered, owing to the retardation 
of absorption. 

Thirty minims of solution of morphine (1 : 100) with 1 minim of 
atropine solution (1 : 100) can be safely given by the mouth, and half 
these quantities may be repeated every two, three, or four hours, as the 
pain and collapse warrant. 

Chloroform or ether should not be employed at this stage, as the 
vomiting which often follows their inhalation may seriously mislead 
the physician, and aggravate the patient's suffering. 

Hot poultices of linseed meal, or cold compresses or ice bags, accord- 
ing to the patient's sensations of comfort, may be applied over the 
entire abdominal surface. Bryant lays great stress upon the value of 
belladonna externally as a means of quieting peristalsis. He also 
gives the drug internally by the mouth or as a suppository, and prefers 
it to opium. He records some interesting successes recently from treat- 
ment which might be thus summed up : The recumbent position, with 
elevation of the pelvis, so as to allow gravity to act toward the thorax, 
starvation, rectal feeding, belladonna and glycerin externally, and 
belladonna and opium internally. 

If a purgative has not already been administered, which is too fre- 
quently the case, the physician should not only abstain from pre- 
scribing it, but he should warn the patient and his friends of the danger 
of attempting to have the bowels moved by this means. Even when 
the case is strongly suspected to be one arising from fecal accumulation-, 
purgation is fraught with very considerable danger at this stage of the 
obstruction. 

Enemata may, however, be administered with comparative safety 
and considerable advantage. To do so to best advantage requires 
attention to several important details : The patient should be turned 
over upon his left side, the shoulders should be lowered, and a hard 
pillow or cushion placed under the pelvis, so as to favor the gravita- 
tion of the fluid along the colon. 

The syphon apparatus is preferable to the India-rubber suction or 
the old-fashioned piston appliance. Should these latter be employed, 
the greatest gentleness and patience must be exercised, so as to prevent 
premature reflex contractions of the colon or rectum. Tepid water 
alone, without soap, castor oil, turpentine, soda, or other irritant, is the 
best — the object being to throw up as much liquid as possible without 
causing its return by stimulating the bowel. This may be assisted in 
some cases by turning over the patient upon his back, and afterward 
upon his right side, so as to assist the passage of the fluid toward the 
ileo-csecal valve. At a later stage this object may be favored by the 
abdominal taxis. 

The administration of the enema should not be intrusted to any other 
hands, but should be carried out by the attendant himself. By pausing 



418 INTESTINAL OBSTKUCTION. 

occasionally during the operation (without removing the tube) until the 
temporary spasm of the bowel subsides, large quantities of fluid may 
be introduced. 

The writer believes that the use of O'Beirne's long tube is a serious 
mistake ; he has never seen any advantage from it, but, on the con- 
trary, he has witnessed mischievous irritation produced by its use. 
The enema may afford considerable relief by ridding the colon 01 its 
contents ; it may dislodge an impaction, unfold a twist, or even remedy 
an invagination. It is also, in some cases, of great value in clearing 
up a diagnosis, and if given with the care just now recommended is 
very unlikely to do any mischief. 

When the symptoms of acute obstruction show no signs of yielding 
to starvation, rest, opium, local applications, and copious enemata, there 
are still other measures worthy of trial before resorting to laparotomy. 
Where the case is suspected to be one caused by the strangulation from 
a band, volvulus, or invagination, the next procedure may be followed 
by success. 

Abdominal taxis, to be carried out to its fullest extent, should be 
only attempted after the administration of chloroform or ether. The 
patient lying upon his back, the surgeon should massage or knead the 
abdominal contents with considerable force applied by both hands, until 
every region has undergone thorough manipulation. Then the body 
may be inverted, and when in this position, with the feet uppermost 
and the head down, it may be shaken, as Hutchinson recommends, up 
and down. Afterward the patient may be turned back upward, and 
his body shaken backward and forward, and to and fro. Enemata are 
recommended to be administered when the body is completely held in 
the inverted position by strong assistants, and their use in this manner 
may be regarded as a part of the abdominal taxis. By these means 
there is some hope that a loop of intestine may be untwisted, or a coil 
pulled out of an aperture, or an invaginated portion unfolded, or a 
knuckle withdrawn from under the constriction of a band. If the 
abdominal taxis is carried out in the above thorough manner, it is only 
admissible in the early stages, and its repetition is useless or dangerous 
later on. The distended loop, the seat of volvulus, or of constriction 
by a band, may be fearlessly tapped by a fine trochar and canula 
thrust through the abdominal wall. The spontaneous reduction of the 
strangulated coil has been known to follow the withdrawal of the gas. 
It is not admissible, however, where there is reason to believe that the 
coats of the bowel are seriously diseased or inflamed. Where intus- 
susception is believed to be present, and copious warm water enemata 
have been tried in vain, the bowel may be distended by pumping in 
air through the rectum by means of a pair of bellows, a Higginson's 
syringe, or an instrument devised for this purpose. Sulphuretted 
hydrogen or pure hydrogen has been similarly used. 

Carbonic acid gas has been successfully employed in some cases. It 
can be generated in the bowel by injecting a solution of bicarbonate 



INTESTINAL OBSTRUCTION. 419 

of soda, followed by a solution of tartaric acid ; or syphons of the 
gas may be used conveniently. The inflation of the bowel by bellows 
is more* satisfactory, as the amount of air required may be measured, 
to a certain extent, by the resistance and by the tension of the walls 
of the abdomen. Many cases have been cured by these means, but 
the practice is not without serious danger, as the pressure may, espe- 
cially in infants, cause rupiure of the bowel, and there is some like- 
lihood of the intussusception being only partially relieved or reduced, 
in which case the symptoms return with intensity after a temporary 
amelioration. 

Inflation is not only useless, but is distinctly contra-indicated where 
the invagination is of long standing, or where there is evidence of 
acute general peritonitis, gangrene, or adhesions. 

Metallic mercury has been administered. The writer knew of one 
case of obstruction from intussusception where more than three pounds 
avoirdupois of the liquid metal was administered by pouring it through 
a funnel and tube into the stomach. Though the obstruction was re- 
lieved, the patient died several weeks afterward from what was supposed 
to be the result of an indiscretion in diet. It is not, however, a method 
to be recommended, being very liable to destroy the bowel, or cause 
serious trouble by its retention afterward. It has, however, been em- 
ployed occasionally in fecal obstruction successfully. 

Nothnagel still recommends the use of metallic mercury as harmless 
in recent cases. 

Where a very large impacted gall-stone causes symptoms of acute 
obstruction from blocking up of the small intestine, rest, opium, and 
abdominal massage have been followed in several cases with success. 

The application of a strong interrupted current to the abdominal 
walls has been known to remove symptoms of acute obstruction, and 
some physicians recommend the introduction of one pole into the 
rectum. The best method of using electricity for this purpose is to 
use a strong continuous current. Boudet makes a solution of salt 
injected into the rectum to act as one electrode. He passes a current 
of 40 milliamperes for five minutes, after which he reverses it and in- 
terrupts it every twenty seconds. Excellent results are reported after 
this treatment. 

Washing out of the stomach may give considerable relief, and may 
be resorted to pending the completion of arrangements for a more 
serious operative interference. It is indicated where the vomiting is 
distinctly stercoraceous and is always palliative, and may possibly be 
curative. Rectal feeding, by nutritious or peptonized enemata, may be 
called for where vomiting is incessant and collapse well marked. 

Where success does not immediately follow the employment of the 
various measures already described, the operation of laparotomy should 
be decided upon without further delay. The writer can recall vividly 
many cases in his own experience where the post-mortem revelations, 
or the knowledge acquired in later years, would justify him in saying 



420 INTESTINAL OBSTRUCTION. 

that had laparotomy been performed it would have probably saved 
life. The practice of opening the abdomen in such cases dates back 
from a comparatively recent period, yet innumerable lives have been 
saved from it during the last ten or twelve years. The high mortality 
is sure to yield when, by common consent, the operation is undertaken 
at an earlier stage of the disease. Delay is dangerous, every hour in- 
creasing the chances of a fatal termination, though Dr. W. B. Kich- 
ardson maintains that laparotomy need not be seriously entertained 
until the onset of fecal vomiting, after which it is imperative. 

The abdomen should be opened in the middle line between the um- 
bilicus and pubes. There is no advantage in making a very free 
incision, as the object of the surgeon is to prevent the protrusion of 
the intestines. A wound sufficiently large to admit the entire hand is 
generally more satisfactory than a larger one. In the case of intus- 
susception in children, it may be well to attempt exploration through 
an incision large enough to freely admit two fingers. Further extension 
of the opening can be easily made afterward, if necessary. 

In those cases where laparotomy is undertaken for obstruction which 
a previous herniotomy has not relieved, or where the case is complicated 
by the presence of an old hernial sac or scrotal tumor of doubtful con- 
tents, it is, notwithstanding the advice of eminent authorities, better to 
make a fresh median incision than to cut down upon the neck of the 
tumor, or prolong inguinal incisions previously made. The writer has 
assisted at four operations where abdominal incisions were extended 
from the region of Poupart's ligament or the inguinal canal, and the 
subsequent steps were most seriously complicated thereby. The median 
incision would have saved life in one of these cases. 

Greig-Smith lays great stress upon the dangers and disadvantages 
of anaesthetics in operating for abdominal obstruction. He states that 
the anaesthetic increases shock where such increase can ill be borne, 
and that it has a special risk of its own as tending to induce vomiting, 
which may suffocate the patient. The distended stomach should be 
emptied by passing the stomach-tube before anaesthesia is begun, or, at 
least, before it is complete. The anaesthesia should be continued no 
longer than is necessary to make the parietal incision and place the 
sutures ready for tieing — that is to say, from three to five minutes. 
All further manipulations may be carried out without pain to the 
patient while he is recovering from the anaesthetic. It is wonderful 
how little these patients feel and how quietly they will lie and languidly 
watch the proceedings being carried out for their salvation. 

The abdomen being opened under antiseptic precautions, and the 
intestines prevented from protrusion by the application of warmed 
aseptic sponges or flannel cloths, the surgeon should insert his hand 
and make in a bee-line for the ileo-caecal valve. Should there be 
much difficulty in doing so, the distended coils of intestine may be 
freely punctured with a fine trochar, though it is often surprising to 
find in some cases how little additional room is gained by this proce- 



INTESTINAL OBSTKUCTION. 421 

dure. The coecum being found in a distended condition, the surgeon 
knows that he will come upon an obstruction in the large intestine by 
following the course of the bowel from the valve toward the rectum. 
Where there is any great difficulty in doing this he may begin anew at 
the upper part of the rectum, and proceed upward in the direction of 
the transverse colon and valve, pursuing his exploration methodically 
and leisurely until he arrives at the seat of the obstruction. Upon the 
same principle the small intestines are to be explored, passing each 
portion rapidly through his fingers. If a band or diverticulum is 
found to be the cause of the strangulation it is to be divided and the 
imprisoned coil or knuckle of bowel set free, an internal hernia may 
be reduced and an intussusception drawn out by pulling gently upon 
the upper part and squeezing or kneading the lower portion from be- 
low upward. Where reduction of the invagination is found to be im- 
possible, enterectomy should be performed, and this is also applicable 
where gangrene has supervened. When the obstruction cannot be 
discovered, the most prominent coil of distended bowel should be 
sutured to the abdominal wound, and an artificial anus then pro- 
duced. 

Obstructions caused by gall-stones or foreign bodies are to be dealt 
w 7 ith by incising the bowel, and suturing the wound with catgut and 
returing it. 

Strictures are best treated by enterectomy, and when situated in the 
large intestine must be met by colotomy or colectomy. 

Volvulus of the sigmoid flexure may be best treated by performing 
a left lumbar colotomy. When failure attends all other means of re- 
lieving fiecal accumulations, colotomy may be entertained as a means 
of giving relief. This should, however, be avoided until the pro- 
longed use of copious enemata, cautious attempts at purgation, and 
the supervention of urgent symptoms, prove that further delay is 
useless. 

The treatment of the chronic forms of intestinal obstruction, or of 
the acute forms supervening upon the chronic, is to be carried out 
upon the same general principles as those already mentioned. Pre- 
ventive or palliative treatment by judicious dieting must not be for- 
gotten, and the physician should not be tempted to postpone laparot- 
omy until the supervention of perforation or general peritonitis renders 
its success almost hopeless. Nelaton's operation or enterotomy, whereby 
an artificial anus may be established in the small intestine, is indicated 
in those cases where the seat of obstruction is beyond reach. It may 
be performed by making an incision above Poupart's ligament upon 
the right side. After entering the abdominal cavity, the first coil of 
distended bowel presenting in the wound is sutured to the margins of 
the skin incision by a double row of sutures, after which the bowel is 
freely opened between the sutures. 

Greig-Smith, in speaking of those cases where there is great difficulty 
in finding the cause or seat of the obstruction, says : " I think it wiser 



422 iritis. 

at once to perform enterostomy than to spend much time groping about 
for the cause of the obstruction. The fact that enterostomy or abdom- 
inal drainage will, even if the cause of the obstruction has not been 
touched, rescue a patient from death, is sufficiently well established to 
want no emphasizing from me." 

The after-treatment is to be carried out upon general principles as 
in the case of herniotomy. 

INTESTINAL HEMORRHAGE- See Melama. 
INTESTINAL INFLAMMATION— See Enteritis. 
INTUSSUSCEPTION— See Intestinal Obstruction. 
IRITIS. 

The first thing to do is to administer a smart saline purge, and drop 
into the eye a few drops of solution, of sulphate of [atropine (1 : 100). 
Should pain be a severe and prominent symptom, cocaine should also 
be freely used. A drop or two of a 4 per cent, solution may be in- 
stilled, or a cocaine disc may be inserted behind the lid every two or 
three hours, or hypodermic injections of morphine may be required. 
When there is much congestion, three or four leeches applied to the 
margin of the orbit or temple give great relief. As a rule, if wide and 
uniform dilatation follows the use of atropine, the case will soon yield. 
If there be much plastic exudation, and the atropine fails, to enlarge 
the pupil widely, it must be pushed every three or four hours with the 
view of dragging upon the adhesions. Mercury should be freely given 
in all cases where this result is not speedily obtained. In syphilitic 
cases the action of the mercury must be kept up until there is evidence 
that the constitutional effects of the drug have been produced, after 
which the dose may be diminished. Salivation is seldom necessary, 
and should be avoided. Mercury is essential in all cases of iritis with 
much exudation of lymph, but in non-specific cases its action may be 
suspended as soon as this disappears. The influence of atropine should 
be maintained until it is clear that the danger of adhesions has passed 
away. 

In serous iritis, and sometimes in the plastic variety, it may be 
found necessary to tap the anterior chamber by inserting a fine 
cataract-knife into it in front of the iris, and this may be repeated 
if the fluid accumulates again. 

With a distinct rheumatic history, salicylate of soda may be given 
in full doses, also where mercury is indicated, but cannot be toler- 
ated. 

Turpentine in full doses internally (10 minims every four hours) 
has been proved to possess remarkable power in causing absorption of 
exudations. Duboisine, pilocarpine, colchicine, homatropine, and 
physostigmine have been recommended, but the general management 



JAUNDICE. 423 

of a case of ordinary iritis may be summed up in the words — rest, 
atropine, and mercury. 

When the rapid increase of the plastic exudation threatens to close 
up the pupil, it may be necessary to speedily produce the constitutional 
effects of mercury by inunction in severe cases. 

Good results have been obtained by injecting about 3 grain of 
calomel, suspended in glycerin or weak mucilage, into the tissues in 
the neighborhood of the margin of the orbit. 

The treatment of suppurative iritis and of irido-choroiditis is to be 
carried out upon the same lines as in severe iritis, the severe pain being 
relieved by cocaine and morphine hypodermically. 

Sympathetic iritis must be promptly met by enucleation of the 
primarily affected eye and the frequent instillation of a weak sub- 
limate solution into the secondarily affected eye. 

Where, in spite of atropine and mercury, or where the case has 
been negleted from the first, and adhesions have formed which refuse 
to yield to atropine, they should be treated by operative measures as 
soon as it is clear that they are the cause of secondary attacks of 
iritis. Their destruction may be accomplished by inserting a minute 
hook through an opening in the cornea and lacerating the adhesions 
by traction, or the operation of iridectomy may be performed. 

ITCH— See Scabies. 

JAUNDICE. 

The treatment of jaundice cannot properly be detailed here. It is 
but a symptom of a large number of totally distinct affections, and the 
most appropriate management of these will be given under their sepa- 
rate headings. (See Gall-stones, etc.) For the jaundice itself there 
cannot be said to be any specific treatment ; but there are, fortunately, 
remedial agents of value which may be palliative, even when the cause 
of the jaundice is irremovable, as in cancer, tumors, impacted calculi, 
etc. The first object of the physician, then, is to treat the cause. This 
is very often, for example, owing to a catarrhal condition of the stom- 
ach, the inflammation creeping from the gastric mucous membrane into 
the duodenum and up the bile duct. As already described, this con- 
dition soon yields to appropriate remedies, such as mild purgatives, 
judicious diet, bismuth and alkalies, with minute doses of morphine 
and counter-irritation. 

There is in a large proportion of cases of jaundice no discoverable 
cause, as remarked by Fagge, who applies the term " simple " jaundice 
to such, and the question arises, Is there any safe efficacious treatment 
applicable in these instances ? Any attempt to treat a symptom of 
this complex kind, about whose pathology there is so much uncertainty, 
is open to the imputation of quackery, and, as Duckworth has put it, 
" the recommendations of any drug for the treatment of a symptom 
depending upon so many possible causes can hardly receive serious 



424 JAUNDICE. 

attention unless a full diagnosis of the cases has been established. " 
Where, however, a full diagnosis is impossible, and where upon no 
other grounds than mere empiricism a certain drug has been used and 
found by some observers to produce good results, there can be no valid 
reason why it should not receive serious attention, especially if it be 
free from the objection of being dangerous and harmful. The most 
that can be said in these cases is that such good results are open to 
question, especially as it is known that these examples of jaundice are 
very likely to end in spontaneous recovery. 

Of remedies of this class the common ragweed (senecio jacoboea), 
recommended by the late Dr. Charles Purdon, is a typical example. 
He found that teaspoonful doses of fluid extract (1 : 1) had a marked 
influence in dissipating the jaundice. 

Vichy and Carlsbad waters on the Continent, podophyllin, euony- 
min, and iridin in small doses in America, and alkaline soda, potash, 
ammonia salts at home have long been maintained to exert decidedly 
beneficial action in simple jaundice. The following combination is 
often prescribed : 

R . — Sodii bicarb ' . . ^jss. 

Pulv. rhei . ^ij 

Pulv. zingiberis giv. 

Pulv. calumbee gvj. 

Pulv. ipecacuanhse et opii 3j. — M. 

S. — A small teaspoonful in half a tumblerful of patash water, to be taken every 
four or six hours. 



The following liquid preparation may be used 

& . — Ext. taraxaci fld 

Sodii bicarb 

Tinct. rhei 

Infus. gentianse ..... 
S. — A tablespoonful to be taken three times a day. 



• 3YJ. 
. gjss. 
ad gxij. — M. 



Where alkaline agents are not admissible, benefit may be derived 
from the favorite acid remedy — dilute nitro-hydrochloric. This may 
be given in doses of 20 minims, well diluted with a weak, bitter in- 
fusion, three times a day, before meals, and 25 grains of the chloride 
of ammonium may be given at bed- time in warm whey. The diluted 
acid may be also applied locally, or used as a bath. 

Calomel and other mercurials should not be employed in simple 
jaundice, except as occasional purgatives, when they may be followed 
by a morning draught of Friedrichshall water, sulphate of magnesia, 
sulphates of potash or soda, phosphate of soda, or Carlsbad salt. Ene- 
mata of cold or tepid water may be employed daily. 

The value of pilocarpine will be presently referred to. Quinine and 
arsenic may be found useful in cases of malarial jaundice. 



JAUNDICE. 425 

The diet should be as simple as possible. A skim-milk diet the 
writer believes to be the best in such cases. Sugar, fats, and alcoholic 
stimulants should be avoided. Butchers' meat is best given in the 
form of beef-tea. Rice and other farinaceous foods may be allowed. 
Hot baths and hydropathy, as will be mentioned, are valuable aids to 
treatment. 

There may be legitimate doubts expressed about the value of the 
above-named remedies in dissipating simple jaundice. They possess 
one advantage,, however — that, used as recommended, they can do no 
harm. 

Where the symptoms indicate the presence of gall-stones, the various 
measures mentioned upon page 268 should be pressed into the service, 
and when the obstruction is complete, operative interference may be 
the only remedy available. 

When permanent jaundice has been established, or where there is 
evidence that the icterus is dependent upon obstruction, the most that 
can be done is to assist Nature in her efforts to eliminate the re- 
absorbed bile. There can be no question that substances capable of 
exerting a marked effect upon the liver or duodenum, as full doses of 
calomel, podophyllin, soda salts, or euonymin, are distinctly contra- 
indicated in these cases. Purgatives are required, but only such as 
exert no well-marked hepatic action should be selected. Salines are the 
best, and they may be preceded by aloes or other cathartic of the same 
class. 

In this way the natural purgative effect of the bile, which in the 
normal condition flows into the intestines, may be kept up, and portal 
congestion at the same time will be diminished. 

The bile, however, exercises important functions in health, assisting 
the absorption of fats, and preventing fermentative and putrefactive 
changes occurring in the intestinal contents. It is, therefore, advisa- 
ble to supply a substitute as near as possible to the natural fluid in 
chemical constitution. In the official fel bovis purificatum this is 
obtained. It is, however, so seldom employed that, when ordered by 
the physician an old, effete sample is likely to be supplied by the 
chemist. Ten grains of the fresh preparation, in pills, may be ad- 
ministered three or four times a day. 

Where the absence of the natural bile has led to diarrhoea, resulting 
from the irritation of decomposed or putrefying intestinal products, 
the best thing to do is to administer an intestinal disinfectant. The 
best is turpentine, given in large doses, in the form of a capsule, 
which, if swallowed when the stomach is quite empty, may be found 
to pass directly through into the intestines, where it will exert its anti- 
septic properties to best advantage. Creasote may be given in the 
same way, or charcoal, also in the form of capsule. Naphthalan, boric 
acid, or other antiseptic may be employed. 

As the bile is chiefly eliminated by the kidneys in obstructed jaun- 
dice, diuretics, as copious draughts of warm liquids, or even members 

28 



426 . JOINT DISEASE. 

of the stimulating diuretic class, as broom, digitalis, iodides, etc., may- 
be employed with much advantage. The skin should be kept in the 
best condition by wearing warm clothing, and resorting to the warm, 
hot, or Turkish bath, or by using a hot or wet pack every evening. 

There is one very important drug which may be used with much 
advantage in jaundice from obstruction. It relieves the distressing 
itching of the skin after warm alkaline baths have failed. Pilocarpine, 
administered hypodermically, in doses of about J grain, relieves this 
distressing symptom for twenty -four or thirty six hours; it is, in fact, 
the only remedy for this purpose on which much reliance need be 
placed. Most glowing reports come from Witkowski, who claims that 
injections of % grain, once or twice a day, will act as a specific for all 
cases of simple hepatogenous jaundice. It is even affirmed that, where 
speedy disappearance of the icterus does not occur, that it may be 
taken as strong evidence that the disease is cancer of the liver, and 
not simple jaundice. It is, however, certain that this is too strongly 
stated as obstructive jaundice, not depending upon cancer, has been 
seen to resist pilocarpine. There cannot be any doubt, however, that 
in this drug we possess the most useful remedy yet known in the treat- 
ment of simple or obstructed jaundice, and it will be worth trial in all 
cases where the diagnosis is doubtful, and it may be employed in con- 
junction with any other form of treatment. 

Excellent results have been from time to time reported of Gerhardt's 
method of treating all cases of catarrhal jaundice in children and 
adults. It may be useful in the obstruction caused by small calculi, 
and is carried out by passing a smart faradic current through the gall- 
bladder, by placing one pole over the spine and the other over the 
distended organ, so as to produce brisk contraction of the muscular 
fibres of the gall-bladder. 

The treatment of infantile jaundice is most unsatisfactory. The 
ordinary icteroid tinge appearing upon the skin of children a few days 
after birth is, however, hardly worth mentioning. It is probably caused 
by the habit of half-smothering up all newborn infants in flannels. It 
rapidly disappears upon the administration of a purgative, and a liberal 
supply of fresh air. 

In cases where jaundice supervenes before birth, or comes on with 
deep conjunctival staining soon afterward, no remedy appears to stop 
the commonly fatal issue. The writer has seen an instance where about 
ten infants of one healthy mother perished in this way. He did not 
try pilocarpine in any of the cases, as its action was then unknown, 
but it would not likely have been efficacious, as in one instance there 
was congenital absence of the gall- bladder, though in a subsequent 
birth there was no malformation, though the infant died twenty-four 
hours after being born deeply jaundiced. 

JOINT DISEASE. 

In detailing the treatment of hip-joint disease, the principles which 
should guide the surgeon have been enumerated. They may be briefly 



JOINT DISEASE. 427 

stated in a general way as applicable to the treatment of most joint 
affections. Inflammation of the synovial membrane will be mentioned 
under Synovitis. 

The first look-out in dealing with a case of chronic joint affection 
(articular ostitis) in its earliest stages, is to improve the standard of 
health in every -way possible, by pure air, good food, healthy surround- 
ings, and the use of constitutional aids to improve nutrition, as cod- 
liver oil, malt extract, and peptonized foods, etc. Where any general 
tendency to struma, syphilis, rheumatism, or other blood condition 
prevails, appropriate remedies should be exhibited. In all cases, iron, 
iodides, arsenic, phosphates, quinine, and other tonics, should be given 
in the early stage of the affection. 

Rest is essential, it should be as thorough as circumstances will 
permit. Absolute rest of the affected joint must be aimed at, though 
it will not be often attained. It may be attempted in various ways if 
the joint be a large one — hip, knee, or ankle — the patient should be 
confined to bed until the acute symptoms pass off, after which locomo- 
tion may be permitted, when immobility has been secured by means of 
proper splints or unyielding encasements. This rest must be pushed 
until all heat, redness, and pain disappear. The mistake of keeping a 
joint too long in a state of absolute repost is a serious one. Ankylosis 
may result, and this termination, though undesirable, and to a certain 
extent unsatisfactory, is one that the surgeon may be glad to hope for 
in bad cases. The limb, therefore, should be placed at the very start 
in such a position that, should ankylosis occur, the subsequent useful- 
ness of the joint will be the least interfered with. 

Where pain is prominent, and does not yield to rest, warm fomenta- 
tions, hot poultices, cold compresses, evaporating lotions, Leiter's tubes, 
or ice may be employed, the selection depending chiefly upon the 
patient's sensations of relief as either application is made. As a rou- 
tine method, nothing surpasses the old-fashioned method of soaking 
narrow strips of lint in spirit lotion (spt. vini rect. 1 and water 2), 
enveloping the joint with them, and covering all over with a layer of 
oiled silk, gutta-percha tissue, or thin mackintosh. It is applicable to 
the most acute acute and to the most chronic cases where pain is 
prominent. 

Where there is much throbbing pain and congestion the application 
of leeches gives much relief. Like cold, leeching is contra-indicated 
in very chronic cases, except when the patient is suffering acute pain 
from the supervention of active mischief in a joint long affected with 
articular trouble. 

Extension by means of weights and a pulley, as described under 
hip-joint disease, or by means of suitable splints in the case of other 
joints, is a valuable means of diminishing inter-articular pressure, 
though it doubtless exercises beneficial action in other ways. 

When the more acute symptoms have been thus combated, and all 
pain has disappeared for a time, passive motion may be carefully com- 



428 JOINT DISEASE. 

menced, the surgeon feeling his way cautiously. Many joints have been 
hopelessly destroyed by rest prolonged long after the inflammatory 
action had subsided. It is this mistake which enables the unscrupu- 
lous bone setter to thrive. Getting a chronic joint affection in which 
all inflammatory action has long ceased, owing to treatment by some 
surgeon whose timidity prevents him beginning passive or forcible 
movements, the bone-setter pronounces the limb to be " out of joint," 
and, after a few forcible movements, he assures the patient that he has 
" put in " the joint, and the mobility and painlessness of the limb 
which follow apparently corroborate his statements. When the value 
of early massage and movements of a passive or forcible nature are 
universally appreciated, the principal occupation of the bone-setter 
will be gone. 

When there is much thickening from exuded inflammatory products 
outside the joint, or effusion into the synovial sac, pressure by neatly 
applied strapping or Scott's dressing is of much use. A Martin's 
elastic bandage or massage may succeed when these fail to cause 
absorption. 

Abscesses should be freely opened as soon as the physical signs 
clearly point to the presence of pus. Where deep-seated pain, limited 
to a very small area, has been continuous for a considerable period, 
the surgeon need not wait for pointing, but may cut down upon the 
spot and remove any piece of dead or suspicious bone by a small gouge. 
Trephining may be resorted to in some cases with excellent results, 
where the localized mischief can be reached without opening the joint. 
Sinuses may be divided and scraped and afterward swabbed with strong 
solution of chloride of zinc, and the small cavities of necrosed bone 
may be touched with strong sulphuric acid. 

When it is evident that the joint has become disorganized it may be 
freely incised and washed out with an antiseptic solution, free drainage 
being provided by the introduction of moderately -sized tubes. This is 
a fairly satisfactory operation in cases of simple suppuration of a large 
or small joint, but it gives very poor results in chronic articular ostitis. 
The method of opening and thoroughly scraping out the interior of the 
joint, by which every scrap of diseased tissue is thereby removed, is in 
many respects to be preferred to excision. This operation, known under 
the names of arthrectomy or erasion of a joint, is certain to materially 
alter the future of excision. It is not applicable to the hip articulation 
owing to its shape and structure, but in the knee excellent results may 
be anticipated from this modification of conservative surgery. (See 
under Knee-joint Disease.) 

Where erasion is not suitable — i. e., in those chronic joint affections 
where the mischief extends for some distance into the ends of the 
bones entering into the joint, a modified excision or a combination of 
erasion and excision may be tried. When these means are not admis- 
sible, owing to the extensiveness of the disease there is no resource left 
but to amputate. 



KELOID — KNEE-JOINT DISEASE. 429 

The new treatment recommended by Koch for the treatment of joint 
disease depending upon tuberculosis will be found detailed under the 
article Tuberculosis, and Lannelongue's new method of attacking the 
bacilli by deep injections of chloride of zinc will also be found there. 

For the methods of Billroth and Bruns of treating chronic suppu- 
rating joints by the injection of iodoform see under Abscess, page 15. 

JOINTS, Inflammation of— See Synovitis. 
KELOID. 

Two distinct affections are embraced under this name. Unfortu- 
nately for the present purpose, the confusion is of little moment, since 
each is almost equally beyond the range of remedial measures, though 
both may spontaneously resolve and disappear. 

Extirpation of the hardened patches or tumors is generally followed 
by return in a more active form. Where the affected part can be 
covered with an unirritating plaster, as the emp. adhesivum, or emp. 
hydrargyri, and protected from all sources of irritation or annoyance, 
the best results are obtained. Pressure by an elastic bandage, where 
the situation of the growth permits, gives best results. 

Electricity, electrolysis, iodides, mercury, arsenic, chloride of gold, 
and other remedies used with the view of promoting absorption, are 
useless. Caustics in rare cases have been followed by improvement, 
but far more frequently by an increase of the growth. The pain and 
uneasiness which often attend the affection must be met by appropriate 
remedies. Anodynes like opium, analgesics like antipyrine, cocaine, 
exalgirie, or large doses of bromides may be called for. 

KERATITIS— See under Cornea (page 150). 

KIDNEY DISEASES— See under Bright's Disease and under 
Movable Kidney. 

KNEE-JOINT DISEASE 

Under Synovitis the main points indicating the treatment of the 
inflammation of the synovial membrane of the knee will be found. 
Under Hip joint Disease (page 364) and under Joint Disease (page 
428) will be found the chief measures applicable to chronic articular 
ostitis. These may be briefly repeated. They are indicated in all 
cases of disease involving the cartilages or ends of the bones entering 
into any articulations in the body. As chronic disease of the knee- 
joint so frequently has its origin in struma, constitutional remedies are 
of vital importance. Fresh air, free ventilation, seaside resorts, good 
food, warm clothing, massage, and every possible measure calculated 
to improve nutrition and raise the standard of health should be attended 
to. The drugs to be depended upon in such cases may be mentioned 
in their order of merit — cod-liver oil, iodide of iron, malt extracts, 



430 KNEE-JOINT DISEASE. 

hypophosphites, bichloride of mercury in very minute doses, arsenic, 
and chloride of calcium. 

Local measures, as already mentioned, will embrace absolute rest by 
means of splints or extension. While active mischief is present the 
entire limb should be rendered immovable. Pain is to be met by cold 
or warm applications, counter-irritation by means of blisters or the 
cautery iron, leeching, or anodyne liniments or lotions. As the more 
active symptoms subside, it is of the very greatest moment that the 
patient should be rescued from the atmosphere of his bedroom, and 
tempted to spend as large a portion of the day as possible' in the open 
air. By means of a plaster-of-Paris casing or a leather splint this may 
be managed without much danger, but the application of a neatly-fit- 
ting Thomas's splint is much better. When it is in use the joint is 
open to daily inspection or to the convenient application of local reme- 
dies, as iodine liniment, lin. potas. iod. cum sapone, B. P., spirit or other 
lotion. By a raised boot and crutches the patient can freely move about 
without running much risk, and pain may disappear. 

Strapping over mercurial dressing may be applied at a later date, or 
the pressure of a Martin's elastic bandage may be tried. 

Abscesses should be freely opened ; and if a continuous localized pain 
over a spot in the head of the tibia, or over either condyle of the femur, 
should lead the surgeon to suspect a localized abscess in the cancellous 
tissue, trephining may be seriously contemplated where this is rendered 
possible without opening into the joint. 

When, however, in spite of all these measures, matters go from bad 
to worse, and the joint becomes hopelessly disorganized, several proce- 
dures are available. The most valuable are : 

1. Arthrotomy may be performed — i.e., the joint maybe incised, 
washed out, and drained. 

2. The joint may be incised, and lint saturated in a mixture of strong 
sulphuric acid (1 part) and water (2 parts) may be inserted, after 
washing out with an antiseptic lotion. By this means, pulpy synovial 
growths may be dissolved. The method is useless unless where the 
disease is confined to the synovial lining of the joint, and at the best it 
is most tedious, and very often ends in failure. Occasionally, however, 
a firm ankylosis results. 

3. A lateral incision may be made upon each side of the patella, and 
the pulpy diseased membrane may be scraped away with a Volkmann's 
spoon. This is seldom successful, as it is impossible to remove more 
than a comparatively small portion of the diseased tissue, and in the 
typically strumous joint the removal of every portion of the affected 
tissues is essential. 

4. These two methods may be combined. After lateral incisions 
have been made, and as much of the diseased membrane as possible has 
been removed by Volkmann's spoon, sulphuric acid may be freely and 
repeatedly used with the view of causing destruction of the remainder. 
Though the joint may be left in a better condition for the subsequent 



KNEE-JOINT DISEASE. 431 

establishment of ankylosis than if either procedure alone had been em- 
ployed, nevertheless the same objections remain, and another is super- 
added in the danger of destroying healthy tissue unnecessarily. 

5. The operation of arthrectomy or erasion may be performed. This 
is really method No. 3 systematized and carried out to its very fullest 
extent, It has been advocated and performed with decided success by 
Wright and Edmund Owen, who agree in stating that in suitable cases 
of diseased knee-joint it is better surgery than excision. Owen's paper 
in the Transactions of the Medico Chirurgical Society, vol. lxxii , is a 
valuable addition to the surgery of the knee-joint. The operation is 
not applicable to the same extent in the treatment of other large joints. 
It is based upon the theory of the infective or invading nature of the 
microorganisms supposed to be always present in chronic joint disease, 
and upon whose presence in some small fringe or crevice of the dis- 
eased membrane which escapes removal in other operations, failure 
depends. Its great advantage over excision lies in the fact that it is 
essentially a conservative operation in that it does not remove any 
healthy tissue, while, at the same time, it is an extremely radical one 
in that it insures the taking away of all material of a dangerous or 
suspicious nature. It is, like all measures short of amputation, contra- 
indicated by the presence of extensive disease of the articular ends of 
the. bone. Ankylosis generally results, but a good limb may result 
w T ith moderately free movement — a result midway between that obtained 
from incision and excision. 

The following is Owen's description of the operation : " The opera- 
tion is commenced by making a bold horse-shoe incision from the 
tuberosity of one femoral condyle nearly to the tubercle of the tibia 
and up to the other tuberosity of the femur. The incision opens the 
joint and divides the ligament of the patella. Bleeding vessels are 
caught by the self-holding forceps. The crescentic flap with the patella 
is then turned up, and if the subcrural pouch of the articular cavity is 
not thereon fully exposed, the horns of the incision may be prolonged 
upward to the necessary extent. Every ulcerated surface of articular 
cartilage or bone is then scraped over or scraped out, all pellets and 
fringes of the synovial membrane are sliced off with curved scissors or 
scalpel, the semilunar cartilages are taken away, and the crucial liga- 
ments are dissected out. The end of the femur is then trust out of the 
wound, and the posterior surface of its condyles, and the synovial 
recesses above them, and the posterior part of the capsule of the joint, 
are thoroughly scraped. (When scraping the front of Winslow's liga- 
ment the azygos artery is likely to be wounded and to bleed somewhat 
vigorously.) The subcrural pouch is then thoroughly explored and 
scraped, the articular surface of the patella is also scraped, and if it be 
much affected it may be sliced off, but the bone should be taken 
away. 

" When, to the entire satisfaction of the surgeon and his assistant, 
every suspicious area has been efficiently dealt with, the large cavity is 



432 KNEE-JOINT DISEASE. 

thoroughly washed out with a hot solution of chloride of ziuc or car- 
bolic acid. 

" If the head of the tibia has been long displaced on to the outer 
femoral condyle, and the scraping which its inner tuberosity has 
received, does not suffice to allow of the leg being adjusted in a per- 
fectly straight line — and this often happens — the articular surface of 
the inner femoral condyle must be sliced away until the desired position 
is attainable. Certainly the bones must not be allowed to become 
ankylosed with a valgous inclination. 

" Provision is then to be made for efficient drainage: Upon this 
much of the ultimate success of the operation depends ; and as the 
cornua of the Avound cannot be depended upon for draining the post- 
condylar recesses, I am in the habit of boring a hole from inside the 
joint through the ligament of Winslow, using a pair of scissors for the 
purpose. The position of the popliteal artery having been made out, 
the index-finger of the left hand is lodged in the hollow along the inner 
side of the biceps tendon, aud the skin is traversed at that spot. Oc- 
casionally I have drained through the space between the artery and 
the inner hamstrings. It matters not where the drain is so long as it 
is efficient. Pus cannot drain uphill. If the tube be passed from the 
anterior and through the posterior wound, heed must be given that it 
is not nipped between the femur and tibia when the limb is brought 
straight. On the whole, it is perhaps better to drain solely by the pos- 
terior opening, closing the anterior wound entirely with the exception 
of its cornua. The limb is then bandaged from the foot upward, the 
knee being surrounded by absorbent mercuric wool, and fixed upon 
the straight back splint, care being taken that the heel does not press 
upon the pad. The less after this that the limb is disturbed the better. 
The drainage-tube is soon withdrawn, the wearing or starting pains 
have entirely ceased, and though it must be many months before the 
limb is serviceable, the disease is probably at an end, and convalescence 
is established." 

6. Excision of the joint is performed by making a curved incision 
through the skin, extending from the posterior part of one condyle to 
the corresponding part of the other. After dissecting up the integu- 
ment from the front of the patella, the joint is freely opened by a 
clean sweep through the ligamentum patellae and lateral ligaments. A 
thin slice of bone is to be sawn off the lower end of the femur and the 
upper end of the tibia. The diseased pulpy membrane is to be removed 
by the knife, scissors, and scraping, the freshly sawn surfaces of bone 
placed in close apposition, suitable drainage provided, sutures adjusted, 
and the immobility of the limb insured. 

The operation of excision of the knee cannot be said to have met the 
sanguine expectations of its earlier advocates. To insure success it 
must, generally speaking, in the opinion of the writer, be undertaken 
at a stage so early that a natural cure is still possible if the operation 
be deferred. (See under Hip-joint Disease, page 366.) It is contra- 



LABOR. 433 

indicated where there is evidence of extensive bone mischief, and in 
those subjects run down by prolonged exhaustive suppuration, and in 
most patients past the age of thirty years. 

7. When there is evidence of bone disease extending a considerable 
way beyond the diseased joint surfaces, where the patient is past middle 
life or exhausted by prolonged suffering or suppuration, and where the 
constitutional symptoms clearly show that the system is unequal to the 
long demand which an arthrotomy, arthrectomy, or excision would 
entail, and especially where other organs are already showing signs of 
breaking down, the only legitimate operation will be that of an ampu- 
tation through the lower third of the femur; 

For Koch's method of treating diseased joints arising from tuber- 
cular disease, see under Tuberculosis, where also is detailed the still 
more recent method of Lannelongue, who injects chloride of zinc into 
the tissues surrounding the tubercular deposits. Under Abscess, upon 
page 15, will be found a brief description of the method of Bruns, who, 
after aspiration of the joint, injects a sterilized emulsion of iodoform 
at various points. Bilroth's operation is a modification of the scraping 
method just detailed, and of the iodoform injections of Bruns. 

LABOR. 

The management of a case of natural labor need not be here 
described in detail, the student or practitioner being already quite 
familiar with the essential points discussed in every text-book on mid- 
wifery, regarding the relative duties of nurse and accoucheur, position 
of the patient, preparation of the bed, instruments to be carried, making 
examinations, passing the catheter, administering enemata, chloroform, 
bandaging, etc. 

The free use of antiseptics should be emphasized, though the present 
tendency toward the injection of mercuric solution after every exami- 
nation made during labor is unwarrantable. The attendant should 
thoroughly cleanse his hands, and, after the use of the nail-brush, he 
should dip them for a few moments into a weak sublimate solution 
(2 grains in 10 ounces), or carbolic lotion (1 : 50), and as a lubricant, 
carbolized lard or oil (1 : 20) may be employed. The golden rule 
should be that, the less interference and manipulation the better for 
the patient. When all goes well, the first duty may be to assist nature 
by pushing upward the swollen (edematous anterior lip of the os, which 
may be, in some instances, retarding the descent of the head. This is 
generally accomplished without difficulty, if not attempted too soon, by 
pushing up the congested lip with the tip of the right index-finger 
before a pain comes on, and keeping it above the symphysis until 
the pain passes off and the head descends a little. In this way 
progress may be accelerated by pushing the oedematous tumor over 
the descending vertex, assisted by gentle abdominal pressure from 
above. 

As the head reaches the outlet and presses upon the perineum, this 



434 LABOR. 

structure must be protected from laceration as far as possible. Unfor- 
tunately, the means too often employed to prevent this accident may 
determine rupture. Strong pressure directed against the tense perineum 
generally aids laceration. In many cases a slight delay gives the tissues 
time to dilate, and this may be all that is necessary. By strong, direct 
pressure against the perineum, the uterine pains are increased in force 
and frequency, gradual natural dilatation is prevented, and laceration 
is more liable to occur. Hence, some authorities recommend the patient 
to be encouraged to cease, as far as possible, from making expulsive 
efforts, in order to give longer time for the natural dilatation or stretch- 
ing of the part. For a similar reason, others advise direct pressure 
upward and backward against the head. 

The mose frequently-practised manoeuvre for the support of the 
perineum is carried out by placing the left hand against the perineum, 
while the fingers of the right hand are pressed against the head. In 
this way extension of the head and retardation of its descent are at the 
same time accomplished. Much more power over the head is obtained 
by pressing against the forehead or orbital margins by means of two 
fingers inserted into the rectum. Ritgen's manoeuvre is carried out 
by placing four fingers of the left hand between the tip of the coccyx 
and anus, while the head is distending the perineum. In this spot 
the brow and both jaws may be felt, and by pressing, at the end of 
a pain, the head is prevented from receding, and may be even ad- 
vanced, while the occiput is kept close to the pubic arch, and rotation 
is assisted. 

Dr. Gaussen has recently drawn attention to another method by 
which the shortest foetal diameter of the head may be made to pass 
through the ostium vaginas. He aids the movement of flexion by 
traction on the occiput, with two fingers of the right hand inserted 
behind the symphysis, and as the head is about to clear the ostium, he 
renders flexion complete by grasping the occiput in the hollow of the 
right hand, and as he pulls it down from behind the pubes, the frontal 
part of the vertex is pushed upward and backward toward the sacrum 
with the thumb of the same hand. 

Free lubrication of the perineum may be employed in all cases 
where there is threatening laceration, and where there is much rigidity 
an incision with the knife or scissors may be resorted to. After labor 
has been completed, one or two deep sutures should be inserted by 
means of a curved needle. For sutures to be of use, they should be 
employed at the time. They are unnecessary, except when the lacera- 
tion is extensive, and they are useless after a delay of twenty- four or 
forty-eight hours. (See Perineum — Rupture of.) 

After the birth of the head, the accoueheur should see that the cord 
be loosened if it surrounds the neck, and the perineum should be still 
closely watched during the exit of the shoulders, which may require 
both traction and rotation. 

As soon as the head has cleared the ostium vaginas and the cord has 



LABOR. 435 

been removed from the neck, if present, the uterus should be firmly- 
grasped by the left hand (see page 316), applied to the surface of the 
abdomen, and steady, gentle pressure is to be maintained while it is 
felt to diminish in size as the shoulders, trunk, and lower extremities 
are born. 

After a short pause the pressure upon the uterus may be increased, 
in order to hasten the expulsion of the placenta. If this does not show 
signs of coming away after a short delay, two ligatures may be applied 
to the umbilical cord, and its section with scissors accomplished mid- 
way between the ligatures so as to separate the child from the mother. 
Several authorities maintain that this separation should not take place 
until the umbilical vein has collapsed, otherwise a loss of two or three 
ounces of blood is suffered by the infant. Spiegelberg consequently 
advises that the child should not be separated from the mother until 
after the expulsion of the placenta, or at least not until the latter is 
beyond reach of the uterine pressure. 

By firm pressure applied to the uterus, which should be squeezed 
and kneaded alternately between the thumb and four fingers of the 
left hand, the placenta, as a rule, is generally expelled from it with- 
out much delay. When it has been found to enter the vagina, mod- 
erate traction upon the cord soon brings it within the grasp of the right 
hand, when it can be easily extracted entire along with the membranes 
by a rotatory movement. Undue haste and anxiety in the removal of 
the placenta is to be avoided, as by these means irregular contraction 
in the uterus may be set up. 

The invariable custom of the writer is to keep up the uterine con- 
traction for a considerable time after the expulsion of the placenta, in 
order to guard against hemorrhage, and with this object he does not 
apply the binder or abdominal bandage until after the infant has been 
washed and dressed by the nurse. Thus an interval of nearly half 
an hour is left, during which the uterus may be watched, felt, and 
kneaded for a few moments, and all clots expelled. If the abdominal 
bandage and pad be immediately applied after the termination 01 
labor, little can be known about what is going on in the uterus. It 
is a good rule to give a large dose of ergot after the removal of the 
placenta. 

Post-partum hemorrhage is to be met by the remedies mentioned 
under Hemorrhage, page 316. 

After the expiration of the first twenty-four hours, the nurse should 
be directed to wash out the vagina with a weak antiseptic solution. Of 
all the agents of this class, permanganate of potassium is the most 
harmless, and, therefore, the one best suited for routine use. Where 
septic mischief is especially feared, weak corrosive sublimate solutions 
should be employed ; but it is better to reserve powerful remedies for 
special indications, and direct the nurse, as a matter of routine, in 
every case to inject a pint or more of a mixture of Condy's fluid and 
water (a large tablespoonful to one pint of tepid water) morning and 



436 LABOR. 

evening. It is needless to say that this injection or douche should be 
used when the patient lies upon her left side or back, with a bed- pan 
slipped under the nates. The practice of getting out of bed upon the 
fourth or fifth day, as followed by women of the working classes, is 
fraught with much danger, and it is a wise rule to confine the lying-in 
woman to bed for a minimum period of eight or nine days. Robust 
patients may be sometimes permitted to get up after seven days, and 
weakly patients in whom the process of involution is tardy, had better 
be kept in bed for fourteen days. Not uncommonly, mischief is 
done by insisting upon a too prolonged repose in the horizontal 
position ; but there is more danger to be feared from the patient 
moving about the room and working with her infant after she is per- 
mitted to leave her bed. For ordinary healthy women it is wise to 
name the middle of the fourth week as the best time to venture out 
into the open air. 

The bowels require close attention. When there is time, a mild 
purgative or warm- water enema should be given at the commencement 
of labor, and no further interference in this direction is called for until 
the third day, when a mild laxative will help to check any great tension 
in the breasts. Castor oil, in doses not exceeding 2 or 3 drachms, 
is the safest of all purgatives at this time. Where there is marked 
feverishness and constitutional disturbance, with fulness of the breasts, 
6 drachms of Rochelle salt in half a bottle of aerated lemonade may be 
given, and repeated in four or six hours, if necessary. 

The condition of the bladder will require watching, and the catheter 
may be required from time to time. 

The bedclothing should be light, and the lying-in room kept cool 
and well ventilated, and it should be kept protected from the visita- 
tions of sympathetic and officious friends. 

The diet for the first two days should be chiefly liquid, any ordinary 
fever dietary being selected, as weak tea and thin slices of toast, boiled 
bread and milk, gruel, rennet, etc. Upon the third day beeftea, 
chickensoup, and eggs may be allowed, followed in a day or two by boiled 
chicken, fish, steaks, chops, or roasts. The over-cautious, starvation 
method often does much harm, especially to suckling women, and from 
the first, milk may be allowed in small quantities at a time, but as 
frequently as the patient desires it. Where there are special reasons 
which hinder the mother from nursing her child, the diet should be 
as free from liquids as possible. Dry biscuits and unbuttered toast 
may be given, with very small quantities of meat. 

As a rule, alcohol in some form should be always in the lying-in 
room, but it should be in a sealed bottle, never to be used except in 
some rare emergency, and then only under the special directions of the 
medical man. The practice of forcing nursing mothers to drink large 
quantities of porter, ale, or wine is a serious mistake. For all pur- 
poses milk in some form is all that is required, and good buttermilk, 
when procurable, is the best liquid nourishment after the first week for 
nursing mothers. 



LARYNGISMUS STRIDULUS — LARYNGITIS. 437 

The treatment of the various complications which may arise during 
or after labor will be mentioned under their different headings through- 
out this volume. (See Hemorrhage, Post-partum, page 315 ; Perineum, 
Rupture of; Puerperal Fever, etc. For Ophthalmia Neonatorum, 
see under Conjunctivitis, page 135.) 

LARYNGISMUS STRIDULUS. 

This true neurosis is not to be confounded with false croup, though 
it is sometimes called by that name (see page 155). It is also often 
spoken of as laryngeal spasm, child crowing, spasmodic croup, etc. 

Depending, as it does, in some way upon abnormal reflex excita- 
bility, and often associated with rickets, the treatment will resolve 
itself, to a great extent, into the treatment detailed under the headings 
of Rachitis, Delayed Detention, Infantile Convulsions, etc. If seen 
during the attack, which is seldom, as the onset is alarmingly sudden, 
and its duration exceedingly brief, the best thing to do is to dash a 
little cold water against the face and chest, and afterward plunge the 
patient into a warm bath. A whiff of chloroform may be administered. 
Faradization of the recurrent laryngeal, tracheotomy, or artificial 
respiration, or the forcible pulling forward of the tongue may be 
resorted to if the physician should happen to be present at an attack 
which does not yield to a dash of cold water. Ammonia to the nostrils 
may also be tried. 

There is no time generally for the action of an emetic, unless in those 
cases where successions of attacks follow each other. Amyl nitrite 
should be worth trial, though the writer has never known of its use in 
this affection. In the intervals between the attacks, the diet and 
hygienic surroundings of the infant should be scrupulously attended 
to (see under Rachitis). 

Of drugs, a certain amount of success has followed the use or 
bromides, chloral, musk, castor, morphine, emetics, nitro-glycerin, 
succus conii, and belladonna. The writer has obtained the best results 
from full doses of the bromide of ammonium, of which 2 or 3 grains 
may be given every three hours, or oftener, to a child one year old. 
Henoch speaks highly of morphine, pushed to the extent of causing 
drowsiness, but this treatment cannot be free from serious dangers, 
especially as the disease rarely, if ever, occurs except between the 
fourth and twenty-fourth months. Lancing of the gums may be 
tried, but there is little benefit to be expected. Recently antipyrine 
in small doses (1 grain every hour for a child one year old) has been 
reported as successful in preventing the return of the paroxyms. 

LARYNGITIS. 

Acute inflammation of the larynx, though to a variable degree an 
element in croup (see page 155) is for the most part easily distinguish- 
able at the bedside. 



438 LARYNGITIS. 

Fagge separates croup from acute laryngitis by the broad distinction 
that in croup there is the dangerous dyspnoea, while in acute or acute 
catarrhal laryngitis the prevailing symptom is impairment of the 
voice. 

The treatment is to be carried out upon the same principles as those 
fully detailed under croup. 

The patient should be directed to give his larynx as much rest as 
possible, speaking being forbidden. He should he placed in bed in a 
warm room, the air of which should be saturated with the vapor of 
water. This may be accomplished by the use of the bronchitis kettle 
or by any of the various steam inhalers. The vapor of the compound 
tincture of benzoin may be used with advantage, the B. P. inhalation 
of conium, or the diluted vapor of a small quantity of weak tincture of 
iodine or carbolic acid. 

Poultices, or warm fomentations, or spongio-piline, wrung out of hot 
water, should be applied to the larynx — the latter is the most conve- 
nient and soothing. Cold may be tried where warmth is found to 
aggravate. Warm demulcent drinks should be freely administered 
and perspiration encouraged. The following mixture for an adult is 
suitable, and where the symptoms are urgent an emetic may be first 
administered : 



R. — Liq. amnion, acetat. 



ad 



§ij- 



3y- 

gr- j- 
3x.— M. 



Vini antimonii .... 

Morph. hydrochlor. 

Ext. conii fid 

Aquse camphor. .... 
S. — One tablespoonful to be taken every four hours. 

Tracheotomy may be called for, and the after-treatment will be 
similar to that described under croup. 

As the more urgent inflammatory symptoms are relieved, if pain 
persists it is best relieved by the following solution, which can be freely 
used as a spray every three or four hours or oftener : 

H . — Cocainse hydrochlor gr. x . 

Glycerini acid, carbolici (1 : 6) .... gijss. 

Aquae rosae ad ^x. — M. 

S.— To be used occasionally as a gargle, and frequently as a spray. 

As the symptoms pass off a weak gargle of tannic acid, 1 drachm in 
8 ounces infusion of roses, may be used with advantage.* 

The treatment of chronic laryngitis as a cause of hoarseness has 
already been briefly referred to (page 367). The management of such 
cases is often most tedious and unsatisfactory. Rest of the vocal 
organs for a time is essential, and though every constitutional disturb- 
ance or error is to be corrected by improved hygienic surroundings, 
including change of residence for a time to a bracing or mild atmos- 



* LARYNGITIS. 439 

phere, nevertheless the most striking results are always to be obtained 
by local remedies. 

Nitrate of silver, used either in solution (30 to 60 grains to 1 ounce 
water) or as the mitigated or solid stick should be applied to the 
interior of the larynx every two or three days. The latter is a very 
severe and painful remedy. Often a weak solution (20 grains to 1 
ounce) brushed daily over the interior of the larynx gives better 
results than the stronger solutions, w T hich can only be used at consider- 
able intervals. Chloride of zinc (2 grains to 1 drachm) is the best 
remedy when a purely astringent effect is desired. 

These strong local applications can only be made by the physician 
— a serious drawback in the treatment and management of a chronic 
disorder — and hence the great value of sprays and inhalations, which 
can be used by the patient as often as deemed desirable. Of the 
astringent spay solutions the following are the best : alum 5 grains to 
1 ounce), tannic acid (5 grains to 1 ounce), chloride of iron (5 to 10 
minims of the weak liquor to 1 ounce), sulphate of zinc (2 grains to 1 
ounce), sulphate of copper (1 grain to 2 ounces), and when an altera- 
tive effect is desired tincture of iodine (4 minims to 1 ounce), chloride 
of ammonium (10 grains to 1 ounce). 

Bromide of ammonium (5 grains to 1 ounce), eucalyptus oil (2 
minims to 1 ounce), fir- wool oil (2 minims to 1 ounce), bichloride of 
mercury (-§- grain to 1 ounce), ipecacuanha wine (100 minims to 1 
ounce), sulphurous acid (* drachm to 1 ounce), may be employed. 

Where dysphagia, pain, and irritable cough are distressing, a spray 
which the writer has found most useful is that formulated upon page 
438, containing cocaine and carbolic acid. 

Inhalations are useful when a soothing effect is desired, though other 
actions may be obtained by using various volatile substances in this 
form. Conium inhalation, hot water containing eucalyptus, terebene, 
fir-wool oil, creasote, menthol, carbolic acid, iodine, benzoin, or Friar's 
balsam, may be each advantageously used as an inhalation, 

Good results may be obtained from the chloride of ammonium 
inhaler. Pinus pumilio oil, 15 minims to 1 pint water at 160° F., is a 
grateful inhalation. Insufflations employed by blowing finely pul- 
verized substances, such as mixtures of powdered starch, bismuth, and 
morphine, are seldom followed by much relief. 

The constant current, faradization, or static electricity may be tried 
with benefit in some cases of chronic laryngitis. 

Rheumatic laryngitis is a very chronic and troublesome affection. 
Ingals has found benefit follow its treatment by the astringent and 
soothing sprays and inhalations mentioned above, but he relies mainly 
upon constitutional remedies directed to the diathesis, as iodide of 
potassium, salicylates, colchicum, cimicifuga, and guaiacum. 

Tubercular laryngitis. Within recent years, especially since Koch's 
discovery of the bacillus tuberculosis, there has been marked activity 
and some progress made in this little corner of the field of therapeu- 



440 LARYNGITIS. 

tics. The treatment of tubercular disease of the larynx, as of any- 
other region, will be feeble and unavailing if not directed chiefly 
against the hereditary or acquired condition which permits the growth 
and development of the microorganism. Consequently the various 
agents useful in the treatment of scrofula and phthisis, and every pos- 
sible means whereby nutrition may be improved, must be scrupulously 
attended to before local remedies are seriously decided upon. 

Local treatment may be mentioned under two heads — viz., (1) reme- 
dies used to relieve pain, dysphagia, and cough, and (2) measures 
directed to the removal of the local deposits or injured tissue. 

Rest to the larynx should, as far as possible, be insisted upon, as the 
use of the voice prevents or retards the reparative process. Hot or 
cold currents of air, very hot or very cold foods, are to be also avoided, 
as well as tobacco smoking and the inhalation of irritating dust, etc., 
and the use of much alcohol. A warm, moist climate is much better 
than a dry, bracing atmosphere. 

Cough should be quieted, as far as this can with safety be accom- 
plished, by anodynes internally, and by soothing inhalations or sprays. 

There are diverse opinions held regarding the value of cocaine in 
laryngeal suffering. The writer has satisfied himself of the very great 
comforts which its use affords for a brief period, in many cases beyond 
the reach of relief in any other way. It may be used as the spray 
previously mentioned, or a 10 per cent, solution may be brushed freely 
over the interior of the larynx. Glycerin of borax is a good vehicle 
for the drug. It consists of glycerin 4 parts, and borax 1 part. 

& . — Cocainee hydroclilor . 5 ss. 

Aquae dest. . . 5 ss. 

Glycerini boracis ...... ad ^j. — M. 

S. — To be used as directed. 

Cocaine is also employed in the form of an insufflation and in pas- 
tilles. After the use of cocaine, sometimes the patient can take food 
with comfort when swallowing had been previously distressing or im- 
possible, especially where there has been much ulceration or perichon- 
dritis present, and in the later stages of the disease its use will enable 
the physician to prolong life. 

Insufflations of iodol, or iodoform, mixed with half a grain of finely- 
powdered morphine, have been used to relieve pain and dysphagia. 
The powder should be blown upon the ulcerated spots, the laryngeal 
mirror being always used. Bismuth and boric acid may be also em- 
ployed with morphine instead of iodoform, and the ulcerated spots 
should first be well cleared of mucus before insufflation. 

Neumann, who treats the early catarrhal stage by a solution of 
sulphate of zinc mixed with a 1 or 2 per cent, solution of cocaine, 
speaks in very high terms of the valuable and surprising anodyne 
effects of large insufflations of iodoform in those cases characterized by 



LARYNGITIS. 



441 



extensive tubercular ulcerations. He also uses in less severe cases an 
insufflation of equal parts of boric acid and iodol, and in the later or 
final stages of the disease he finds a 5 to 15 per cent, cocaine solution of 
the greatest use in enabling the patient to swallow. He reports 
highly of lactic acid and tracheotomy, and thinks menthol inferior to 
cocaine. 

Menthol is unquestionably, upon the authority of many specialists, 
of great value in the treatment of laryngeal tuberculosis. It relieves 
pain, acting as a local anaesthetic, and it is claimed for it that it destroys 
the local deposits of the disease. It may be taken internally at the 
same time, applied with a brash, or used as an inhalation, or injected. 

The most satisfactory application for the local use of menthol is a 
solution of 1 part in 10 parts of pure olive oil. This may be brushed 
freely over the affected parts daily for long periods, but it is always 
better to employ a 20 per cent. (1 : 5) solution after the first week.. It 
is not caustic, and its analgesic properties do not become diminished by 
repeated applications. 

A 30 per cent, solution has been used, but it causes considerable pain, 
and is appareutly not followed by better results than those observed 
after the weaker solutions. The effects of the menthol can be kept up 
by the patient wearing a small Coghill's respirator for the greater por- 
tion of the day, with the sponge moistened with a mixture of creasote 
and menthol or other volatile antiseptics. 

The following formula of Mr. Goskar is useful for this purpose : 



-Acid, carbolic 


• • 3ij- 


Creasoti purif. .... 


• • • SJ. 


Spt. chloroformi .... 


• ■ • 3ij- 


Thymol . . 


. gr. xxx. 


Aquae dest. . . . 


. 3xv. 


Spt, vini rect 


. ad §iv— M 



Of measures directed to the destruction of the diseased or ulcerated 
spots there have been many reports from various quarters of successes 
and " cures " after the use of lactic acid. This is used in various 
ways, the simplest being to brush over the affected surface of the 
larynx with a 30 per cent, solution, gradually increased to a 75 per 
cent, solution. Some surgeons prefer to inject a few drops into the 
interior of the larynx with a laryngeal syringe. The pain and irrita- 
tion following the application is much diminished by a previous 
swabbiDg with cocaine. 

Allowing for the enthusiasm of the advocates of this method of 
treating tubercular laryngitis, there cannot be a doubt but excellent 
and lasting good results have been obtained. Some surgeons have 
injected the acid under the diseased mucous membrane, as others have 
injected iodoform, in the same manner and with the same intention. 
The writer has had no experience of the local application of this acid 

29 



442 LAKYNGITIS. 

to the larynx, but he has repeatedly satisfied himself about its striking 
action when applied to tubercular lupus on the face. It destroys the 
diseased tissue, and appears to have no injurious effect whatever upon 
the healthy structures in the immediate vicinity. 

Not content with the action of 80 per cent, solutions of lactic acid, 
Ehring has gone a step further and scraped the ulcerated spots in the 
larynx until he removed all the diseased tissue, after which he applies 
the acid or injects it under the membrane. This he has done in 200 
cases, with the report of twenty-eight cures. Keimer follows much 
the same practice. He rubs the acid in with a brush after curetting. 

Kolischer iujects the acid solution of phosphate of lime, which has 
been found to cause the absorption of tubercular or caseous masses in 
diseased joints. Prosser James, however, justly expresses a note of 
warning, and points out the dangers of these heroic interstitial laryngeal 
injections, and it would seem judicious at present to limit their use to 
the hands of experienced specialists. The same remark might be also 
applied to the deep scarifications recommended and carried out by 
Schmidt, and to the use of the gal vano- cautery. 

Where deep and extensive ulcerations exist, beyond the reach of 
these remedies, there may be nothing left to save the patient from a 
painful death but tracheotomy. 

Where the difficulty of swallowing is great, and does not yield to 
cocaine, it may be necessary to feed the patient through a soft rubber 
oesophageal tube. Thick liquids are more easily swallowed than thin 
ones, and in some cases Wolfenden's plan of getting the patient to lie 
upon a couch or bed with his head hanging down over the side while 
he swallows may be successful. 

Syphilitic laryngitis. The treatment should consist of vigorous con- 
stitutional remedies, suitable to the stage in which the syphilitic affec- 
tion is existing at the time. In the latter part of the secondary stage 
of syphilis, rapid mercurialization should be carried out by inunction 
of mercurial ointment. Laryngeal mischief occurring during the ter- 
tiary stages of the disease is best met by heroic doses of iodide of 
potassium — 20 grains three times a day, after meals, may be given. 
Where the case does not respond to the iodide, and the symptoms in- 
crease in gravity, a course of mercurial inunction should be at once 
commenced. The local symptoms can be best met by the various 
anodyne and astringent sprays and inhalations previously mentioned. 
A weak solution of corrosive sublimate (J grain to 1 ounce) is the best 
spray to use in such cases. 

Insufflations of iodoform are of the greatest use in many cases where 
much ulceration exists, and in the late stages of the disease cocaine 
may enable the starving patient to swallow with ease and safety. 

The solid nitrate of silver may be freely applied to ulcerations, or a 
solution of corrosive sublimate (10 grains to 1 ounce) may be used, 
with the aid of the laryngeal mirror. Sulphate of copper (15 to 20 
grains to 1 ounce) is a favorite local remedy. 



LEPROSY. 443 

Where there is much oedema, free scarifications may be needed, and 
sometimes tracheotomy may be demanded. After treatment may be 
necessary for the removal of warty growths, cicatricial bands or webs, 
or narrowing. 

LEAD POISONING— See Plumbism and Poisoning. 
LENTIGO OR FRECKLES— See Chloasma. 
LEPROSY. 

Notwithstanding the labor expended upon the pathology of this 
terrible malady, it must be still included in the list of incurable dis- 
eases. By absolute isolation of the leprous from healthy individuals, 
and by the isolation of individual lepers, there is no doubt that the 
disease can be stamped out ultimately in districts ravaged by its pres- 
ence. By the judicious and persistent use of certain remedial agents 
the disease may be retarded, and suffering may to a very considerable 
extent, be alleviated. Good food, moderate exercise, free ventilation, 
and as much pure open air as the patient's surroundings will permit, 
may be indulged in to advantage. Agents which improve nutrition, 
as tonics and cod-liver oil, are always useful. Iron, arsenic, iodine, 
phosphorus, mercury in minute doses, and a long list of vegetable sub- 
stances, about whose physiological action. nothing whatever is known, 
have been tried in vain. Of these latter empiric agents there are two 
which have met with results which warrant their recommendation as 
valuable palliatives. Some affirm that in mild cases they are curative, 
but the cases of leprosy which have been reported as cured by their 
use are not believed to have been true examples of the disease. These 
agents are gurjun balsam or oil, and chaulmoogra oil or its active 
principle — gynocardic acid. Both remedies are applied externally 
and taken internally at the same time. Both are unfortunately as 
repulsive as copaiba, and as liable to upset the stomach as this nauseous 
balsam. 

Gynocardic acid in doses of 1 grain may be given in the form of 
pills after each meal, and the chaulmoogra oil may be administered in 
the form of capsules (5 minims in each), one three times a day, or as 
an emulsion or mixed with fresh cream. The dose should be gradually 
increased until the patient can bear no further addition, after which 
maximum amount may be persisted in as long as the patient remains 
able to swallow it without suffering diarrhoea or vomiting. Externally, 
the oil should be freely and forcibly rubbed into the affected regions 
after being diluted with twice as much pure lard (lanoline might be a 
better base for such an ointment). The frictions should be repeated 
several times a day for fifteen or thirty minutes each time, and a cloth 
or dressing saturated with the ointment should be left in contact with 
the diseased surfaces. From the beginning of the treatment the skin 
should never be permitted to get free from this greasy application, 



444 LEUCODERMA OR VITILIGO. 

except for the short time during which the patient is getting cleansed 
from time to time by hot baths, after which the frictions are to be 
immediately resumed. 

Gurjun oil or dipterocarpus balsum, as it is also called, is likewise 
used both externally and internally, and most Indian physicians pre- 
fer it to the chaulmoogra oil. It may be given in the form of an 
emulsion in doses of 5 to 15 minims, or in the form of capsules. In 
India a tablespoonful of an emulsion made by shaking up 2 ounces of 
the oil with 6 ounces of lime-water is given twice a day, but the more 
civilized stomachs will not bear half this amount. 

For external application a liniment made by shaking up equal parts 
of the oil, lime-water, and lard oil, should be rubbed in very often 
with moderate pressure. 

Ulcerations are to be treated upon general surgical principles. 
Unna's ichthyol or resorcin ointments (25 per cent.) are good dress- 
ings to use after applying concentrated carbolic acid where the ulcer- 
ated surface is limited. Iodoform gauze may be employed in some 
cases, but oakum teased out carefully may make a cheap and very 
valuable dressing superior to all others where expense is an important 
object. 

Unna uses a 10 per cent, pyrogallic acid ointment to the limbs, and 
a 10 per cent, chrysarobin ointment to the rest of the body, and in 
severe cases recommends that the tubercles be excised and ichthyol 
given internally for long periods. 

Other antiseptics as creasote and carbolic acid (1 : 10), salicylic 
acid, boric acid, iodoform, creolin, corrosive sublimate, mercurial oint- 
ment, etc., have been used, but with very varying successes. Cocaine 
and morphine may be used to relieve pain and hyperesthesia, and 
Crocker reports that stretching of the affected nerve in non-tubercular 
leprosy has been of much use in relieving paralysis and anaesthesia. 

LEUCODERMA or VITILIGO 

The white, rounded or circular patches in this disfiguring affection 
of the skin are practically beyond the reach of treatment. These 
patches are always surrounded by a zone of skin containing an abnor- 
mal amount of pigment ; and as much of the deformity may be owing 
to the marked contrast between the two colorations, much may be done 
by removal of the increased pigmentation to render the appearance of 
the patient less remarkable. Weak solutions of corrosive sublimate 
(1 to 3 grains to 1 ounce), may be often used with much advantage 
for this purpose when the spots attack the face or upper portion of the 
neck. The writer has been able in one case to very materially improve 
the appearance of a female patient to whom the presence of this affec- 
tion was a serious distress. Repeated applications of small circular 
blisters of the cantharides paper, which may be left in contact with the 
whitened patch for one or two hours at a time, may sometimes induce 
a slight amount of pigmentation. The blister should be a little smaller 



LEUCOCYTH^MIA OR SPLENIC LEUKEMIA. 445 

than the unpigmented area. Internal remedies are useless, and gal- 
vanism is of little or no value. 

LEUCOCYTHiEMIA or SPLENIC LEUKEMIA. 

In the early stages of this disease the reports of most trustworthy 
and eminent authorities prove that permanent recovery sometimes 
follows the use of certain remedies. These remedies are by common 
consent, however, held to be useless in advanced stages of the disease, 
and it comes consequently to be a question if they deserve any credit 
in removing the splenic enlargements and altering the condition of the 
blood when given in the early stages. It must remain at present an 
open question whether the so-called cures have any relation to the 
remedies employed. They might have resolved had no drug been 
employed at all. Until the natural history and progress of the affec- 
tion have been thoroughly worked out by collecting cases in which no 
drugs have been employed, we are likely to remain in some doubt. 
Nevertheless, in the face of statements made upon the best authority, 
it must at present be considered our duty to give accredited remedies 
the fullest trial. When any history of ague has been made out the 
lines of treatment are very clear. 

Improved hygienic surroundings, and attention to every error in 
living is of obvious importance ; and where the patient resides in a 
malarious district, his removal to a healthy seaside resort should be 
early insisted upon when the season permits. 

It is of importance to restrict the exercise of the patient to that of 
moderate activity, as violent movements of the body are not safe when 
a large vascular tumor like the spleen is suspended in the abdominal 
cavity. Chills and sudden variations of temperature are to be guarded 
against by warm clothing and avoidance of wettings. The pregnant 
condition, which is not a very rare complication of leukaemia, requires 
special care, and the lying-in period is not free from hemorrhagic 
dangers and anxieties. 

Of remedies in the early stages, quinine holds the premier position, 
and there cannot be any doubt about its great value in those cases 
where any history of ague can be obtained. It must be given in large 
and repeated doses, such quantities being administered every eight 
hours, as will keep the patient constantly upon the verge of cinchonism. 
Often under its use the enlarged spleen will be found to diminish rapidly 
in size, and gradual improvement set in, in all the symptoms. The 
writer has, however, seen large doses in one very recent case fail to pro- 
duce the slightest effect upon the tumor, but there was no history or 
evidence of malaria, and in spite of constant cinchonism from the ear- 
liest stage of the disease, it progressed steadily to a fatal ending. 

When quinine fails to reduce the dimensions of the enlarged organ 
after a considerable trial, the following drugs in their order may be 
administered with some hope of success : phosphorus, -£-§ grain, in pill, 
three times a day ; iron, in 30 to 45 minim doses of the dialyzed liquid 



446 LEUCORRHCEA. 

preparation after each meal ; arsenic, in the form of Fowler's solution, 
5 minims, largely diluted with water, and given immediately after 
meals, three times a day; iodide of potassium, 10 grains in 2 pills, 
given in conjunction with cod-liver oil, or alone. 

Electricity has a powerful influence over the spleen, and in conjunction 
with any of the above remedies, or alone, a strong, continuous current 
should be sent through the enlarged organ, one pole being placed on the 
ribs behind, and the other upon the abdominal parieties over the centre 
of the tumor in front. The electrodes should be enlarged and well 
covered with layers of leather, and moistened with warm saline solu- 
tion, and the current from twenty Leclanche" cells may be employed 
twice a day, for fifteen minutes each time, reversing and moving the 
electrodes about. Where no striking effects follow, faradization may 
be resorted to. 

The practice of injecting ergotine into the tumor has not been fol- 
lowed by success sufficient to warrant its routine employment. A jet 
of cold water, directed with moderate force against the left side of the 
abdomen while the patient stands or lies partially immersed in a warm 
bath, has occasionally been followed by a diminution of the tumor and 
amelioration of the symptoms. 

Inhalations of oxygen have recently been reported as successful, but 
this has been denied by many observers. The application of counter- 
irritants is of little value in reducing the size of the enlarged spleen, 
though pain may be relieved in this way. The ointment of red iodide 
of mercury has been employed, but its value is very doubtful. The 
writer has observed some benefit from wearing a large piece of spongio- 
piline smeared over with the liniment of iodide of potassium and soap 
(B. P.), and kept in its place by the pressure of a firm abominal binder. 
It it not easy to determine whether the benefit is owing to the iodide or 
to the pressure in this case, or to the friction sometimes employed in 
rubbing in the liniment. 

In the advanced state of the disease all measures are worthless, and 
excision of the diseased organ has been invariably fatal in leukaemia. 
Some temporary delay has probably occurred to the advance of the 
fatal issue by transfusion, but occasionally it has appeared to hasten 
the end. 

The various complications which arise, such as syncope, hemor- 
rhage, peritonitis, pleuritis with effusion, dyspnoea, anasarca, etc., are 
to be treated upon the general principles detailed under the head of 
each. 

LEUCORRHCEA. 

As this is but a symptom of many different affections, a routine 
treatment is to be avoided. The first thing to do is to determine the 
cause of the discharge. It may arise from uterine displacements, en- 
dometritis, polypi, disease of the cervix, vaginitis, or inflammatory 



LEUCORRH(EA. 447 

conditions of the vulva. The treatment of most of these affections 
will be found under their appropriate headings. 

Often, however, leucorrhoea may be found to depend upon constitu- 
tional conditions, and among weak, overworked young women it appears 
as soon as their unhealthy surroundings, irregular hours, or unwhole- 
some food has reduced their vitality to the extent of producing a 
certain amount of anaemia and interference with digestion or assimi- 
lation. 

In married patients, when an examination reveals an inflamed 
cervical canal or eroded os, the application of a strong caustic, brought 
into contact with the secreting membrane by a piece of cotton wool on 
a Playfair's probe through the speculum, is the first step in the treat- 
ment. Iodized phenol, prepared after the following formula, is the 
best agent for this purpose : 

R. — Iodi purificati ^j. 

Acidi carbolici §iv. — M. 

S. — Make a solution with heat. 

After a few applications of the above, any of the astringent lotions 
to be presently mentioned may be used until the discharge disappears. 
The writer has generally found that few cases of this kind resist one 
or two such applications, if the vagina be partially filled through the 
speculum with about an ounce of finely powdered boric acid, kept in 
position for twenty-four or forty-eight hours by a plug of absorbent 
cotton wool soaked in glycerin of borax (1 : 6). 

Constitutional treatment with iron, tonics, sea-bathing, and change 
of air and scene, and the correction of any dyspepsia, constipation, or 
other departure from health, will greatly facilitate the disappearance 
of the discharge. 

Pure carbolic or strong nitric acid, solid nitrate of silver, strong 
chloride of iron, or acid nitrate of mercury solution, may be applied 
to the interior of the cervical canal, instead of the iodized phenol. 

In the leucorrhoea of unmarried patients, where vaginal examina- 
tions with the speculum are to be avoided if possible, less radical treat- 
ment is generally successful, especially as in a large proportion of these 
cases the discharge is simply vaginal. Here constitutional remedies 
are of the greatest importance, and foremost among them is iron. The 
scale preparations are the most elegant and efficacious, though when 
marked anaemia is present, full doses (30 to 45 minims) of the dialysed 
iron are better. The following is a good formula : 

R . — Ferri et ammon. citratis . . . ... . gijss. 

Acidi citrici ciyst 3\jss. 

Aquae dest §vj. — M. 

S. — Take a tablespoonful three times a day with two tablespoonfuls of "alka- 
line mixture," during effervescence, after meals. 



448 LEUCOBRHOEA. 

The alkaline mixture for the above is made by dissolving 5 drachms 
of bicarbonate of potassium in 12 ounces of distilled water. 

At a later stage, tonics containing quinine and a diluted mineral 
acid may be substituted. Good food, pure air, cold bathing, moderate 
exercise, warm clothing, especial attention being directed to the cover- 
ing of the feet and legs, early hours, and a change of scene, when 
convenient, are to be recommended. 

Local remedies may be used in all cases, but the patient should 
be carefully instructed about their use either by the physician or 
through a nurse. Of the various forms of douche apparatus, the 
best is the simple rubber, Higginson's syringe. It is, upon the 
whole, preferable, in the class of cases immediately under notice, to 
the syphon apparatus with the suspended can and long tube. A soft 
vagina pipe, with the extremity perforated by several apertures, should 
be used. 

The various astringent solutions should be injected warm at first, 
but as the patient hecomes familiar with their use the temperature may 
be gradually lessened until, in summer; liquids of the same temperature 
as the surrounding atmosphere may be used. 

The sitting posture is the most convenient, and the injection or 
douche may often with advantage be administered when the patient is 
in a warm or sitz bath. Two points, frequently overlooked in the 
use of astringent douches, are of much importance : at least 1 quart 
(or 40 ounces) of the solution should be used at each time, and the 
vagina should be first thoroughly flushed out by a stream of warm 
or tepid water before the introduction of the astringent. When this 
latter precaution is not taken, the injection of the remedy may cause 
coagulation of any secretions in the vagina and lower part of the 
cervical canal, and the coagulated or thickened secretion adheres 
tenaceously to the diseased membrane, and prevents the action of the 
solution, or it may even, by its presence, become a further source of 
irritation. 

Moreover, a stream of hot water has been found by itself to be a 
powerful alterative to the diseased mucous surface of the vagina, and 
is a favorite remedy with some physicians who only employ astringents 
after they have found it to fail in reducing the amount of the discharge. 
It is found to act best where there is marked congestion of the vaginal 
or uterine walls. 

Where the ordinary astringent injections and plugging with boric 
acid fail, it is recommended to paint the interior of the vagina over 
with a strong solution of nitrate of silver or other caustic. This should 
seldom be resorted to, though where there is much excoriation or vulvar 
congestion, with intense itching, the 30 grains to 1 ounce solution freely 
applied often gives speedy and lasting relief. The writer's ointment of 
conium is an invaluable sedative in such cases. (See fifth edition of 
Pharmacy, Materia Medica, and Therapeutics, page 412.) Where the 
discharge is profuse, the external surface should be well protected 



LICHEN. 449 

from the irritating discharge by being smeared over with some greasy 
preparation (see Eczema, page 226), and the vaginal douche should be 
used three or four times a day ; in ordinary cases, twice daily will be 
found often enough. 

Remedies in the form of medicated pessaries are, as a rule, objection- 
able. As the mass melts it mixes with the discharge, and makes a dis- 
agreeable mess, which adds much to the patients discomfort. 

Belladonna, creasote, carbolic acid, tannin, iodoform, bismuth, etc., 
are used in this form. 

The following are the usual astringent injectians enumerated in the 
order in which the writer has found them in his experience to be best 
suited for ordinary vaginal leucorrhoea : 

Powdered alum, f ounce to 1 quart of tepid water. 

Powdered borax, f ounce to 1 quart of tepid water. 

Boric acid, f ounce to 1 quart of tepid water. 

Sulphate of zinc, 2 drachms to 1 quart of tepid water. 

Iron alum, 2 drachms to 1 quart of tepid water. 

Tincture of iron, 2 drachms to 1 quart of tepid water. 

Sulphate of copper, 30 grains to 1 quart of tepid water. 

Tincture of iodine, 30 minims to 1 quart of tepid water. 

Carbolic acid, 2 drachms to 1 quart of tepid water. 

Acetate of lead, 30 grains to 1 quart of tepid water. 

Lime-water, injected in its strength, or mixed with as much water. 

Tannic acid, 1 drachm to 1 quart of tepid water. 

Corrosive sublimate, 5 grains to 1 quart of tepid water. 

(This powerful agent is not suitable for constant daily use.) 

Bicarbonate of soda or potash, 2 drachms to 1 quart of tepid water. 

Permanganate of potash, 5 grains to 1 quart of tepid water. 

Chloral hydrate, 40 grains to 1 quart of tepid water. 

Nitrate of silver, 20 grains to 1 quart of tepid water. 

Infantile leucorrhoea is most generally of vulvar origin, and may be 
often treated as a simple intertrigo by absolute cleanliness and a lotion 
composed of any of the above solutions. 

LICHEN. 

The lichen group of skin diseases is still in confusion, some 
authorities describing the different varieties of the affection by names 
which are applied to totally different diseases by other writers. Some 
of the diseases grouped together as lichen have nothing in common 
with each other. Lichen ruber or planus is best treated by arsenic 
internally. It is often most tedious in its response to remedies, but the 
steady and persistent use of arsenic will almost always reward the physi- 
cian in the end. The fullest doses should be persisted in for long periods, 
beginning with 3 minims of Fowler's solution. This amount may be 
cautiously increased utili 8 or 12 minims are given three times a day. 
After reported failure, success is said to have been achieved by the 
hypodermic administration of the drug, freely diluted with water. 



450 LIGHTNING INJURIES AND ACCIDENTS. 

With the arsenic ma}' for a time be combined iron, cod liver oil, and 
every remedy or food which improves nutrition and raises the standard 
of health. Sleep is of much importance ; overwork and worry, with 
irregular hours, has a more aggravating influence than is generlly 
recognized. 

Where arsenic cannot be tolerated, or where it fails to make a 
decided impression upon the disease, the recognized plan of procedure 
is to resort to a mild mercurial course. The biniodide of mercury, in 
the form of minute pilules, each containing -^ grain, may be given 
after each meal. The bichloride is most often used, y 1 ^ grain in solu- 
tion three times a day. Many other remedies have been advised, but 
if arsenic and mercury fail, except phosphorus no other drugs appear 
to have any specific action. 

Locally, the treatment best suited to lichen planus is that which 
gives good results in psoriasis — i. e„ a stimulating tar ointment. The 
liquor carbonis detergens and the oil of cade (1 drachm to 1 ounce of 
lard) are good substitutes for the ordinary tar ointment. 

The treatment must, however, largely depend upon the presence or 
absence of itching. When this is a marked feature, the management 
of the case is difficult. If the papules are confined to a small surface 
of the body, a solution of 1 ounce of bicarbonate of sodium dissolved 
in 30 ounces of water is a good sedative lotion. Where large tracts of 
the skin are involved, hot alkaline baths, frequently administered, are 
indicated. A lotion consisting of 1 ounce of the liquor carbonis 
detergens, 1 ounce of strong solution of acetate of lead, in 40 ounces 
of distilled water, may be tried. The following modification of Unna's 
ointment is often very useful : 

R. — Hydrarg. chloridi corros gr. j. 

Acid, carbolici TTtxxv. 

Ungt. zinci oxidi ^j. — M. 

Carbolic acid or creasote, in the form of ointment (1 : 20), or as a 
lotion (1 : 50), may be used. Nitrate of silver, 20 grains to 1 ounce of 
spt. setheris nitrosi, may be painted over the itching surface when the 
above remedies fail. 

For lichen scrofulosorum the remedies suitable for scrofula are indi- 
cated — i. e., cod-liver oil with syrup of iodide of iron, and at a later 
stage small doses of arsenic in combination with iron. 

Lichen pilaris readily yields to weak alkaline baths and friction, 
followed by the inunction of any bland oil like the oleum olivse or 
cod-liver oil. 

LIGHTNING- INJURIES AND ACCIDENTS, 

Unfortunately becoming rather common since the introduction of the 
electric light as a means of illumination, are to be treated upon general 
principles. The shock or collapse is to be met by the remedies already 



451 

mentioned upon page 133. Thus, warmth and friction to the surface 
of the body with the hypodermic or rectal administration of diffusible 
stimulants such as alcohol, ether, or ammonia ; the cold and hot 
douche alternately, with artificial respiration, may be resorted to. 
Burns and injuries to nerve-trunks are to be treated at a later stage by 
appropriate dressings and massage or a weak continuous current. 

LITHIASIS— See Stone in the Kidney. 
LIVER, Abscess of. 

The ordinary pysemic abscess is to be met by the treatment supposed 
to be useful in cases of pyaemia, but in the vast majority of cases it 
may be regarded as beyond the reach of art. 

In cases where the abscess has resulted from tropical hepatitis, or 
where it has followed some ulceration in the intestines or stomach, as 
not very rarely occurs in this country, the affection is generally sus- 
ceptible to marked improvement or complete cure. 

When seen before suppuration has occurred the hepatitis should be 
met by the remedies to be mentioned further on. When, however, 
the abscess has already formed, and the physical signs warrant a diag- 
nosis of one large abscess, and not a series of small or multiple 
abscesses, the removal of the pus is justifiable. If the operator waits 
for a spontaneous opening he may see the patient sink from exhaus- 
tion or from rapid peritonitis, caused by the internal rupture of the 
abscess. 

The operation is a simple one, and may be performed by thrusting 
in a moderately fine trochar and canula into the swelling, and evacu- 
ating its contents by a Dieulafoy's aspirator. Unless the abscess be 
of very great dimensions it may be completely emptied at once. There 
is often no necessity for the insertion of a drainage-tube. The writer 
has seen one tapping cure the condition. Some operators prefer to 
secure adhesion between the abdominal walls and the sac of the abscess 
by the local application of caustic potash or lime before tapping. 
This is seldom necessary when a fine trocar is used, or when the 
puncture is made in an intercostal space. 

Where there is reason to suspect that a second abscess exists after 
the first has been tapped, the trocar and canula may be withdrawn 
and inserted in another situation, and it has been over and over again 
proved that puncture of the liver in this way does not lead to any 
trouble, but that it has been the means of relieving acute hepatitis 
where no suppuration had occurred. 

The puncture should be made at any spot where the physical signs 
show that pointing would likely to occur if left alone. As a rule, the 
puncture below the ribs is better than in an intercostal space. 

Hepatotomy has been several times performed successfully in urgent 
cases by opening the abdomen freely over the most prominent part of 
the tumor, which is then tapped, the abscess cavity freely opened, and 



452 LIVEK, CIKRHOSIS OF. 

its edges or lips sutured to the margins of the skin wound, after which 
thorough drainage is established, and suitable dressings applied. 
Excision of portions of one or more ribs may be required. (See under 
Hydatids, page 369). 

LIVER, Amyloid Disease of. 

Under the heading of Bright's disease, upon page 79, the treatment 
of amyloid disease of the kidney is briefly described. For amyloid 
liver, which so often coincides with the renal change, the treatment is 
the same, and may be briefly summed up in the removal of the cause 
when possible. Syphilis, pulmonary suppuration, bone disease, or 
chronic abscess, if remedied in the early stage, may be followed by the 
complete restoration of the disorganized kidney or liver. In the later 
stages palliation of the symptoms is the most that can be thought of. 
Of internal remedies, iodine or iodides, with full doses of iron, afford 
the best advantages which can be hoped for among drugs. Life may 
be pralonged by a sojourn at a dry and elevated spot near the coast, 
and a long sea voyage is beneficial. The natural iodine mineral 
waters may be trieii with much advantage, and in conjunction with 
these, large doses (30 grains) of the chloride of ammonium may be 
administered. 

LIVER, Acute Atrophy of. 

The treatment of this affection may almost be regarded as hopeless. 
Where a case has been reported as a success after the administration 
of any remedies, the general tendency has been to regard it as an 
instance of mistaken diagnosis. Success has been attributed to 
copious purgation by salines, and in fatal cases marked temporary 
improvement has been observed by this method of treatment. Hence 
in a disease so formidable saline purgatives may well have an extended 
trial. 

When cerebral symptoms or coma supervene purgation should be 
pushed as far as possible, and the treatment (detailed under Bright's 
disease) suitable to ursemic poisoning should be vigorously carried 
out. High temperature may be treated by large doses of quinine, or 
by the newer antipyretics, and symptoms as they arise should be met 
by remedies administered upon general principles. 

LIVER, Cirrhosis of. 

Under ascites, the treatment of this malady has been briefly men- 
tioned. As it occurs in the great majority of instances among " spirit " 
drinkers, the first step in treatment is to operate very decisively upon 
the cause. Alcohol, in every form, should be forbidden. Where it is 
found impossible to carry out this rule, the physician should insist 
upon whatever alcoholic liquor the patient indulges in, being very 
largely diluted, and taken after meals. The extent to which the dis- 



453 

ease may yield, even when established beyond doubt, is rather under- 
estimated. The writer has had considerable experience of it, espe- 
cially among the male operatives in large linen manufactories, where 
a very common practice among the " hacklers " of flax is to drink raw 
whiskey before commencing their daily work in the early morning, 
previous to breakfast, in order to relieve the chronic bronchitis and 
emphysema which almost constantly result from the nature of their 
employment, which necessitates their being in an atmosphere of fine 
flax dust. Where relief can be obtained by suitable bronchial reme- 
dies, and the hackler or flax-dresser can be made to give up his dram- 
drinking, permanent improvement sets in in the cirrhosed liver. 
Change of occupation is of vital importance in dealing with cirrhosis 
in publicans, barmen, and waiters. It is almost impossible for such 
men to abstain, once they have become enslaved to alcohol, unless a 
new sphere of labor be opened up to them. 

Active open-air exercise or labor is of great importance, and the diet 
should be plain and nutritious. Attention should be paid to the 
amount of liquids imbibed. Where there is as yet no sign of effusion 
into the peritoneal cavity, a liberal allowance of liquid food is very 
desirable. Milk, skimmed, may be taken in large amount mixed 
with an equal quantity of aerated water, and the best diet is a liberal 
fish dinner and breakfast. A few months of vegetarian living often 
give excellent results. In Ireland, buttermilk or the home-made kou- 
miss, mentioned on page 23, affords a most valuable dietary in such 
affections as the one under notice. 

Purgatives are useful at all stages of cirrhosis, and saline cathar- 
tics as Epsom or Carlsbad salts and the various purgative mineral 
waters are the best. By an occasional dose of blue pill given at bed- 
time, followed by a morning saline, the portal system is very power- 
fully influenced. Mercurials should be avoided where there is any 
renal mischief associated with the hepatic lesion. Podophyllin may be 
then employed. 

By the daily administration of one large saline draught before 
breakfast, following the occasional dose of podophyllin or a mild 
mercurial, marked diminution may be repeatedly observed in the 
liver in those cases where considerable enlargement, with induration, 
accompanies or precedes the fibroid change in the organ. Mercury 
may be also given for about a month in small doses, alternating with 
large doses of iodide of potassium, administered for a similar period. 
Murchison attached importance to the action of the chloride of ammo- 
nium, and green iodide of mercury (J to 1 grain, three times a day). 
These remedies, in the great majority of cases, cannot be pushed with 
safety, especially as most of the victims of cirrhosis are suffering from 
gastric troubles. Many of them are debilitated from want of proper 
food, having long since ceased to live with regularity and prudence 
In such cases there is no remedy so frequently applicable as the diluted 
nitro-hydrochloric acid in full doses, combined with a vegetable bitter 



454 LIVER, CIRRHOSIS OF. 

in small amount. It may, moreover, be given at the earliest, and is 
often grateful during the later stages of the disease. As this acid is 
liable to decomposition, it is very often disappointing, and fails to give 
any evidence of therapeutic power. It should consequently be seen 
that the specimen be of moderate age, and that it has been carefully 
preserved in a stoppered bottle. The nitro-hydrochloric acid bath is 
prepared by mixing 1 ounce of strong nitric and 2 ounces of hydro- 
chloric acid in 2 gallons of warm water. A local pack may be 
administered by soaking cloths in the mixture and applying them to 
the abdomen and lower part of the chest. The writer, nowever, pre- 
fers to apply the acid mixture in the above strength upon spongio- 
piline worn under a bandage over the entire hepatic region. As soon 
as any eruption appears the acid may be discontinued, but in some 
cases the mild counter-irritation produced by covering the acid lotion 
with an impervious tissue in productive of benefit. 

The following is a good combination ; it acts directly upon the 
liver, and at the same time tends to relieve the craving for alcoholic 
stimulants : 



R. — Acid, nitrohydrochlor. di 
Ext. tarax. fid. 
Tinct. nucis vomicae 
Ext. cinchona? fid. . 
Infus. chiratse . 



• Siij. 

• Siijss. 

ad gxij.— M. 



S. — A tablespoonful in a wineglassful of water, to be taken four times a day, 
before food. 

When, notwithstanding the change in the patient's habits and the 
use of the above remedies, ascites sets in, the remedies are to be con- 
tinued. Cure is still not beyond hope ; and the writer has seen re- 
covery follow where tapping had been deemed necessary. The treat- 
ment of ascites will be found fully detailed under its own heading upon 
pages 53 and 54. 

In the Gazette Medicate de Strasbourg of May, 1889, an extraordi- 
nary case is reported, where the patient, having been tapped over 
fifty times, drank 8 ounces of the ascitic fluid, and the ascites did not 
return. 

Vomiting may be met by counter-irritation over the gastric region, 
with ice and effervescing mixtures internally. Bismuth, alkalies, 
hydrocyanic acid, and morphine perules (^ grain in each) may be 
tried. Pepsin is useful in some cases, and peptonized food often may 
be very valuable when the condition of the gastric membrane is much 
deranged. Hemorrhage from the bowels, haemorrhoids, diarrhoea, and 
other complications are to be regarded as more or less conservative, 
and not to be interfered with too soon. 

When haBmatemesis is sufficiently serious as to demand interference, 
the remedies indicated are enumerated under Hsematemesis upon page 



LIVER, INJURIES OF. 455 

301. Death not unfrequently occurs from the rupture of varicose 
veins situated at the lower end of the gullet, and for which treatment 
is of little avail. 

LIVER, Cancer of. 

All treatment can at the most be palliative, and is to be carried out 
upon general principles. Thus pain is to be relieved by opium, con- 
stipation by enemata or mild cathartics, vomiting by ice, morphine 
perules (^ grain each), and counter- irritation, and the collection of 
fluid in the peritoneal cavity must be removed by tapping when the 
symptoms become urgent. 

Under Cancer of the Liver, upon page 105, the .recent case where 
Liicke excised the diseased mass is referred to. 

LIVER COLIC— See Gall-stones and Jaundice. 

LIVER, Congestion or Inflammation of. 

Where this is owing to valvular affection of the heart, the appro- 
priate treatment will be found mentioned under Heart — Valvular 
Lesions of, page 352. 

In active congestion or hepatitis from indiscretions in diet, malaria, 
chills, etc., the cause is likewise to be as far as possible removed, after 
which rest, a milk diet, a moderate dose of calomel, followed by purga- 
tives of the saline class, smart counter-irritation, the mineral acids, 
especially the dilute nitrohydrochloric, chloride of ammonium, ipecac- 
uanha in full doses, and in severe cases leeches to the margin of the 
anus may be employed. 

LIVER, Hydatids of— See Hydatids, page 367. 
LIVER, Injuries and Rupture of. 

Absolute rest in the horizontal position, and after the symptoms of 
shock and collapse have been met by appropriate remedies, a full dose 
of morphine hypodermically may be administered. Where there is 
reason to suspect that hemorrhage into the peritoneal cavity is occur- 
ring, ice or Leiter's tubes should be applied over the hypochondriac 
region. The intense thirst, which is often a prominent and distressing 
symptom, is best relieved by sucking small pieces of ice and swallow- 
ing small doses of champagne. 

Peritonitis, when it develops, is to be met by cold applications or 
warm poultices, opium, and the remedies mentioned under Peritonitis. 
Abdominal section has been recommended, the peritoneal cavity being 
thoroughly freed from all clots, after which drainage and the various 
measures employed in the after-treatment of ovariotomy may be car- 
ried out. Wounds of the liver have been recently treated with success, 
after abdominal section has been performed, by "applying the thermo- 



456 LIVER, SYPHILITIC — LOCOMOTOR ATAXIA. 

cautery, by plugging the wound with iodoform gauze, and also by 
suturing the wounded gland tissue. 

LIVER, Syphilitic Disease of. 

The treatment of this affection will consist in the persistent use of 
the remedies indicated in the treatment of the later stages of syphilis — 
*. e., mercury and iodide of potassium, the latter in large doses. Com- 
plications, as pain, peritonitis, jaundice, vomiting, or ascites, being dealt 
with upon the principles already mentioned. 

LOCOMOTOR ATAXIA. 

The treatment of this affection is too often approached in a half- 
hearted fashion. Upon the authority of Erb, at least two cases almost 
completely recovered under treatment. The writer has seen improve- 
ment take place which almost amounted to recovery in one case, and 
he has under observation a patient who has had the disease in a well- 
marked degree for at least twenty-five' years. In this case periodical 
treatment has enabled the patient to hold a responsible position without 
any material increase in his ataxic symptoms. 

As. long as locomotor ataxia is regarded as incurable, the treat- 
ment will likely be carried out in such a way as will give very 
unsatisfactory results. No doubt improvement and long stationary 
periods in the progress of ataxia occur where no drugs have been given, 
nevertheless clinical experience confirms the view that drugs are often 
useful. 

The patient should be placed in the most advantageous position pos- 
sible, excess of mental and bodily fatigue being forbidden, regular hours, 
good nutritious food, and warm flannel clothing from head to foot being 
recommended. 

Of the long array of drugs vaunted from time to time as specifics 
only a few need be referred to, as the greater number of them have 
been found by large experience to be useless or injurious. 

Nitrate of silver has been found more generally useful than any 
other drug. Quarter-grain doses may be given in the form of a pill 
three times a day. Some authorities recommend 1 grain three times 
a day. The great objection to its use is the danger of its causing 
a permanent discoloration of the skin when adminittered for pro- 
longed periods. The oxide in double the above doses is less liable to 
cause gastric disturbance, and appears to be equally valuable. 

The chloride of gold and sodium (U. S. P.) is the drug upon which 
the writer places most reliance. Bartholow has shown that its admin- 
istration tends to produce absorption or atrophy of the connective 
tissue, especially when of pathological formation. No discoloration 
follows its continuous use, and in doses of y 1 ^ grain three times a day 
the writer has not found any drawbacks. It may be given best in 



locomotorJataxia. 457 

pilular form, or in solution in distilled water, without the addition of 
any vegetable substances. 

Arsenic, phosphorus, ergot, calabar bean or eserine, pilocarpine, 
bromides, chloride of barium, and iodides may be tried where gold 
and silver fail to give amelioration of the symptoms, or where they 
cannot be tolerated. 

Much difference of opinion exists about the relation of ataxia to 
syphilis. This is a matter of much moment in treatment. 

Iodide of potassium, in full doses (5 to 15 grains) three times a 
day, has often been found to cause marked improvement. This drug 
is clearly indicated where there is a history of syphilis, but the writer 
has seen benefit from its administration in cases where there was no 
reason whatever to believe that syphilis had ever existed. Occasionally 
it will be found to produce marked influence for good over the light- 
ning pains. 

The association between syphilis and ataxia has been overstated. 
Even where there is a close history obtainable, the disease fails to 
respond to the ordinary anti-syphilitic remedies. 

Bichloride of mercury is, nevertheless, worthy of a trial, and may be 
found not unfrequently to be followed by some steady improvement up 
to a certain point, after which it appears to be worse than useless to 
push it. This is also true of the iodide treatment, whether there is or 
is not a syphilitic history. In one case of very long standing under 
the care of the writer there was a most extraordinary intolerance of 
even infinitesimal doses of the iodide. This was probably a coinci- 
dence. Tonics, like the diluted mineral acids with quinine, may be 
given from time to time during the pauses in the above-named drug 
treatment, but there appears to be a general feeling against the admin- 
istration of strychnine. 

Outside the list of drugs there are remedial agents of decided value 
in the treatment of ataxia. 

Electricity stands at the head of these. Rarely does its steady ad- 
ministration fail in producing some benefit, but, like all the previously 
mentioned methods of treatment, it leads to improvement up to a cer- 
tain point, and, when the symptoms seem stationary for a time, the 
patient tires of treatment until a fresh advance in his troubles urges him 
again to seek some relief from the battery. The continuous current 
gives the best results. 

One pole may be placed upon the upper part of the spine in the 
cervical region, and the other one over the lower lumbar spines, and 
the current from fifteen to twenty Leclanche elements should be 
allowed to pass for about five minutes twice daily. A current, from 
three or four cells, should also be passed through the brain for a few 
minutes. A very good method is to place the positive pole upon the 
upper spines, and drop the negative into a warm or tepid foot-bath, in 
which both lower extremities are immersed for five or ten minutes. 
Where the continuous current fails to afford any signs of improvement 

30 



458 LOCOMOTOR ATAXIA. 

in the patient's condition, faradic electricity has been employed, but it 
seldom will be found to be of any value. The faradic brush has beeu 
very favorably reported upon. In the majority of cases the con- 
tinuous current will be found to have some beneficial effect upon the 
frequency and intensity of the lightning paius. Where these are very 
severe, the current may be applied to give relief at the time by placing 
the positive electrode upon the painful region, and the negative upon 
some indifferent point. 

Static electricity has also given good results, but the writer cannot 
speak from any experience of its action. 

Hydropathy is of use in some cases, and may be carried out in con- 
junction with the gold treatment internally and with electricity. Cold 
packs, the combination of douche and massage, or spray and needle 
baths, with frictions and manipulations applied to the spine and lower 
extremities, may be employed. All warm or hot baths must be for- 
bidden, though Leyden recommends the free use of baths at 86° to 
.95° F., and also of brine baths. 

Counter-irritation has been long tried, and it formerly was a common 
occurrence to find ataxic patients covered from the occiput to the heels 
with marks of old blisters and cautery-irons. Brown-Sequard still 
recommends this practice, and apparently believes in its efficacy in 
cutting short the progress of the disease and relieving the various 
symptoms. 

There yet remains to be mentioned a comparatively new method of 
treating locomotor ataxia which is still receiving a great deal of atten- 
tion from observers in all parts of the world. Suspension, as carried 
out by Charcot, is still too short a time in use to enable one to formu- 
late any positive statements about its permanent benefits. Like every 
other remedy hitherto used in the treatment of locomotor ataxia, the most 
that can be said is that "very great" or "very marked" improvement 
was found to follow its use. No case where a complete disappearance 
of the fully-established disease has been reported as following the new 
method, though, upon the whole, most encouraging reports have been 
furnished. 

There is, however, this great danger that the reports of improvement 
are so exaggerated in some cases as to cause disappointment to those 
who try the method expecting too much. Signs are not wanting that 
this is already occurring, and to some extent discrediting the method. 
The writer has seen considerable improvement follow suspension, but 
his experience is much too limited to justify his forming any opinion of 
its real value. Charcot has found that the ataxia and lightning pains 
are markedly relieved, and a large number of observers have corrobo- 
rated his statement. These improvements have followed a few suspen- 
sions in some cases ; but, as a rule, there are generally no very striking 
results until after about a dozen suspensions, The improvement sets 
in most rapidly in the most chronic and severe cases, and in some cases 
is described as very remarkable. 



LOCOMOTOR ATAXIA. 459 

The first effects noticeable are improvements in walking and steadi- 
ness in standing, in several cases the patient being surprised to find 
that he can dispense with the assistance of his staff, and can stand when 
his heels are brought together. Gradually bladder aud rectal troubles, 
increased or diminished sexual desire, gastric crises, lightning pains, 
giddiness, sleeplessness, anaesthesia, spasm, and paralysis are markedly 
improved. In some cases no amelioration of the symptoms has been 
observed, but in the majority of over 600 cases already reported the 
above beneficial changes have been more or less noticeable in a large 
percentage of them. The absent knee-jerk has only been reported to 
have returned in two cases, and there has been very little of an improve- 
ment observed in vision or in eye symptoms. One of the most constant 
and marked features following suspension has been noticed in the func- 
tions of the genital apparatus, total loss of sexual power and desire 
being very often replaced after suspension by frequent erections and 
sexual appetite. 

Several deaths from strangulation have occurred already by patients 
attempting to carry out self-suspension without professional assistance 
being at hand, but with the improvements recently introduced and to 
be mentioned presently there is very little danger of any such result in 
the hands of a careful physician. 

Of the rationale of this method of treating locomotor ataxia and other 
spinal lesions much has been written and little need be here repeated ; 
suffice it to say, that the discovery of its advantages may be said to 
have been the result of an accident in the first instance. Charcot 
believes that suspension acts like a nerve- stretching operation, and that 
at the same time important changes in the circulation take place. 
Lauder Brunton is inclined to believe that it acts like massage on a 
muscle, and thus insures the removal of waste products and lymph, at 
the same time increasing the processes of repair and oxidation by pro- 
moting a freer blood circulation. Althaus suggests that suspension 
produces its good effects by stretching and breaking down the newly- 
formed connective tissue resulting from inflammatory changes about 
the posterior nerve-roots (which exerts pressure upon the nerve tubules), 
and thus enables them to resume their functions if not already destroyed. 
He thinks that in disease originating in the neuroglia of the cord a 
similar loosening or breaking up of the new connective tissue takes 
place, and provided the axis-cylinders are not already destroyed their 
conductivity may be more or less perfectly restored. The value of the 
suspension treatment of locomotor ataxia, whether curative (which is 
not probable) or merely palliative, is, however, only to be judged by 
careful and impartial reports of large numbers of cases treated by 
competent observers. 

The method of suspension can be carried out by the use of Sayre's 
apparatus, consisting of a tripod and pulleys and hook, from which a 
transverse bar is suspended to which are attached a strap for the occi- 
put, and one for the chin, and one for each armpit. The success of 



460 LOCOMOTOR ATAXIA. 

the suspension will greatly depend upon the adjustment of the chin 
and occiput straps. These must be carefully padded and so applied 
that the pressure is as evenly distributed as possible. The armpit 
straps being adjusted so as to bear a portion of the body weight, the 
patient is gradually and cautiously lifted by pulling on the cord until 
his toes are only left in contact with the ground, when if the straps are 
seen to be properly adjusted, the entire body is completely suspended. 
Half a minute is enough for the first suspension, and this may be 
gradually extended until two or three minutes can be borne with com- 
parative ease. Where a suspension exceeds two minutes -the patient 
should have a few seconds rest. The patient should remove his coat 
and collar, and when suspended his body should be prevented from 
swinging. The proportion of the weight borne by the arm-straps is a 
point of much nicety, and must depend upon the weight of the patient. 
There is no doubt that very little, if any, stretching of the spinal cord 
can take place when a patient is leaning much of his weight upon the 
arm-straps, and where the patient is light they can be altogether dis- 
pensed with, as practised by Hammond who goes further, and with 
very light patients, in addition to a suspension by the head alone, he 
attaches weights to the feet so as to more thoroughly stretch the spinal 
cord. Heavy patients cannot bear suspension by the head alone, and 
at first it is wise to permit them to bear a considerable portion of their 
weight upon the arm-straps, after which, while still suspended, by 
making them abduct their arms the weight can at will be almost en- 
tirely thrown gradually upon the head. 

There are several objections to the tripod. It is very likely to be 
upset by ataxic patients who seize one of the legs in order to steady 
themselves, and it is seldom strong enough to bear very heavy weights. 
There is no question that a simple hook inserted by a long stout screw 
into one of the joists above the ceiling of the physician's study is much 
better. 

By hanging a spring balance between the hook and the cross-bar 
the weight of the patient and the amount of tension can be easily 
ascertained, as suggested by Watteville. The writer has suspended 
patients by both methods, and he has also suspended himself, and the 
introduction of the spring balance or dynamometer appears to take 
away from the discomfort of the performance. 

Weir Mitchell's ingenious apparatus removes most of the difficulties 
just enumerated. He does away with the armpit straps, which, at the 
best, are painful and most unsatisfactory, and for them he substitutes 
two leather slings. The patient, with his arms gently and comfortably 
folded in these slings, can rest suspended for almost any length of time 
without much discomfort. The chin and occiput strap is the same as 
in Sayre's apparatus, but there is the great improvement of two sepa- 
rate pulleys — one for the arms and one for the head. By pulling 
upon the arm pulley the patient is lifted off the ground by his elbows, 
and, when suspended, by pulling gradually upon the cord of the head 



LUMBAGO. 461 

pulley the proportion of weight upon the head can be adjusted with 
nicety. If necessary, all the weight can be transferred gradually to 
the head. This simple and ingenious contrivance is figured in The 
Retrospect of Medicine, edited by James Braithwaite, M.D. Lond. 
Vol. 100 : July to December, 1889. 

As already stated, two or three minutes' suspension is enough, and 
there should be an interval of two or three days. Three times a 
week appears to be the general practice of most of those who have 
published their reports. The writer has adopted the routine method 
of three or four suspensions of sixty seconds each in all cases. 

Suspension is contra-indicated in valvular disease or aneurism, 
phthisis, emphysema, profound ansemia, debility, or obesity. 

It is perfectly certain that this method of treatment is steadily losing 
ground, and that the very glowing hopes raised by the first enthusi- 
astic reporters have not been justified. Nevertheless there cannot be 
a question that it has given better results than all other treatments in 
this practically incurable affection. It is, however, predicted for it 
that it will die a natural death in a few years. 

Bonuzzi has introduced the plan of forcible flexion of the spine as 
a substitute for suspension. It is carried out by forcibly pulling up 
the lower extremities as the patient lies upon his back with a towel 
tied around his ankles. 

The various symptoms of locomotor ataxia are to be met by appro- 
priate remedies. Thus . the action of galvanism and iodide of potas- 
sium upon the lightning pains has already been referred to. 

Antipyrine or antifebrin has also given excellent results in mod- 
erate doses, but sometimes the hypodermic injection of morphine must 
be resorted to. The application of ether spray to the part often re- 
lieves. The lightning pains have also been found to yield to exalgine, 
phenacetin, chloralamide, pilocarpine, and pyrodin or acetylphenyl- 
hydrazin. 

The gastric crisis is best met by smart counter-irritation, with mor- 
phine hypodermically, followed by gastric sedatives. 

LUMBAGO. 

Large doses of salicylate of sodium, 30 to 40 grains of the pure 
salt, may cut short the attack suddenly. Antipyrine or antifebrin, in 
one or two full doses sometimes gives marked relief in the same way. 
If pain is not speedily relieved by these measures, and if it is very 
severe, a hypodermic injection of morphine may be given, and the 
salicylate treatment continued, or salol may be tried. In less acute 
cases the favorite treatment has been also anti-rheumatic, and almost 
every remedy of this class has been tried. Actaea racemosa or cimici- 
fuga, in 30 minim doses of the fluid extract, may be given every four 
hours. 

Large doses of bicarbonate of potassium (1 drachm) in effervescence, 



462 LUMBAGO. 

with one ounce of fresh lemon juice, is an excellent routine treat- 
ment. 

Ten -grain doses of the nitrate of potassium in whey every two hours 
for three doses, then every six hours may be tried. 

The writer has been surprised sometimes to find that speedy and 
permanent relief followed one large dose (a good wineglassful) of gin 
made in the form of punch, and recently he makes this his first step 
in the treatment of all severe and acute cases. 

In chronic cases, where the above remedies have failed, sulphur, 
quinine, turpentine, iodide of potassium, guarana, and caffeine have 
been used with varying success. 

From the above list it will be evident that the constitutional treat- 
ment of lumbago is uncertain, and the same experience will be found 
in the use of local or external remedies. What relieves promptly in 
one case will fail in the next, or in the same patient at some future 
time. The hot-air bath or the ordinary Turkish bath often gives re- 
lief. The warm bath is of little use, but a hot bath (temperature 
106° F.) generally is soothing. 

Hot poultices are not so good as a local hot pack, with a warm 
douche or massage afterward, or dry cupping. 

When the above measures have been carried out, a large thick pad 
of warm absorbent wool, sprinkled over with sulphur, should be ap- 
plied to the painful region, and a firm broad flannel binder or band- 
age adjusted over it. Absolute rest in bed is then to be maintained, 
and the constitutional treatment with the above-mentioned remedies 
is to be kept up. Sedative liniments at a later stage may be rubbed 
in or applied under oiled silk. The following is a valuable com- 
bination : 

Be. — Lin. belladonna? ,^ij. 

Tinct. aconiti iljss. 

Lin. chloroformi ^ijss. — M. 

S. — To be sprinkled freely over lint, applied to the painful region, and covered 
with oiled silk. 

Squire's chloroform of belladonna is also a powerful local sedative. 
The belladonna plaster, and the belladonna extract rubbed up with 
glycerin, are often used, but they make a nasty mess of the patient's 
clothing, and are in no way superior to the liniments. The plaster of 
belladonna mixed with an equal amount of the plaster of opium, and 
spread upon leather, with a very wide non-adhesive margin, is, perhaps, 
the best local application when the patient begins to move about again. 
The back may be strapped with such a plaster when movement con- 
tinues to cause very severe pain. The ether spray or the spray of 
chloride of methyl often gives speedy relief, and ice has been 
recommended as a local application, but its routine use is not to be 
advised. 



LUNG, ABSCESS OF. 463 

Counter-irritation is sometimes recommended at the commencement 
of the attack, though it is more useful at a later stage. Sinapisms are 
lauded, but the writer never used them without finding the pain and 
discomfort aggravated without any apparent benefits. 

Chili paste, or powdered cayenne rubbed up with lard or glycerin, 
is a favorite counter-irritant, so also is strong acetic acid. 

Acupuncture is undoubtedly of great value, and though a paiuful 
remedy, it acts sometimes with surprising rapidity. It may be carried 
out by using the multiple puncture apparatus, or by rapidly inserting 
a stout needle for about an inch into the affected region, at right angles 
to the surface, and withdrawing it quickly. A dozen or more punc- 
tures may be made on each side of the spine. 

Aquapuncture may be carried out in the same way, with the or- 
dinary hypodermic needle, and a little pure water injected each time. 

Carbolic acid has been injected instead of the plain water, in some 
cases, with advantage, and so has nitrite of amyl, in 1 minim doses, 
dissolved in 10 minims of spirit. 

Blisters may be applied in chronic cases, or the actual cautery may 
be used in the form of Corrigan's iron, lightly and quickly pressed 
against the skin, so as to cause a very superficial eschar. The thermic 
hammer may also be used. One of the best methods of treating acute 
lumbago is to cover over the affected region with a piece of stout 
brown wrapping paper, and pass slowly and firmly over this a very 
warm smoothing-iron, such as is used by laundresses, until the patient 
ceases to be able to tolerate the heat. The writer has seen this to 
speedily dissipate all the symptoms of pain, stiffness, etc. 

Of stimulating or mild counter-irritating liniments there is no end, 
thus camphor, paraffin oil, turpentine, eucalyptus, rhus, and others are 
useful. 

Electricity is of considerable value in the treatment of lumbago. 
Occasionally speedy disappearance of all pain has been found to follow 
the early application of a moderately strong continuous current. It 
is the rest routine treatment in chronic or recurring cases when com- 
bined with massage, and the judicious use of warm bathing at resorts 
like Bath, Strathpeffer, Baden-Baden, x\ix-la-Chapelle, Contrexville, 
Marienbad, etc. 

LUNG, Diseases of— See Phthisis?, Emphysema, Pneumonia, 
Asthma, Hydatids, Bronchitis, etc. 

LUNG, Abscess of. 

The diet should be of the most sustaining, the surroundings of the 
patient should be such as will give the best chance of recovery in any 
wasting pulmonary disease. The same rules for ventilation, pure air, 
climatic treatment, etc., may be tried in chronic cases as are indicated 
in phthisis. 

The tendency to bring abscesses and cavities in the lung under the 
dominion of the surgeon is steadily on the increase. Many failures 



464 LUNG, GANGRENE OF. 

from operative interference have occurred, and some successes have 
been reported. There is, however, sufficient progress made to justify- 
fair hopes that the treatment of basilar cavities will become as satisfac- 
tory as in the management of empyema. 

Various means have been tried ; the simplest is to make a free in- 
cision through the tissues in the chest wall, resect a portion of one, 
two, or three ribs, divide the healthy lung tissue slowly by means of 
the thermo-cautery until the abscess cavity is reached, and after the 
evacuation of all pus and debris to ensure thorough drainage as in a 
localized empyema. Where there is complete adhesion of the pulmo- 
nary and parietal pleurae the operation is comparatively free from 
danger, and some authorities secure this by the preliminary application 
of caustics before performing pneumonotomy. Some few cases have 
been reported where a large trochar and canula thrust into the abscess 
cavity between the ribs, has given enough room for the introduction of 
a sufficiently wide drainage-tube. The most suitable cases are those 
where the disease is confined to the lower lobe of one lung and where 
the pleura is adherent. Such cases, whether consisting of simple ab- 
scess, gangrenous abscess, or bronchiectasis are easily treated by this 
simple method. Afterward the cavity can be washed out with warm 
antiseptic solutions. See also under Empyema. 

The aspiration of the abscess or the injection of antiseptics like car- 
bolic acid, creasote, bichloride of mercury, iodoform, etc., into the 
abscess cavity without previous pneumonotomy, seldom leads to satis- 
factory results. Internal remedies have little effect, save those which 
improve the appetite and digestion, lessen fever and reduce hectic. 
Creasote, in full doses, sometimes does much good by diminishing or 
retarding the putrefactive changes in the cavity when operative inter- 
ference is contra-indicated. Volatile antiseptic inhalations or sprays 
may be useful. See under next article. 

LUNG, Gangrene of. 

While every means is being employed to keep up the patient's 
strength and to improve the state of his nutrition, measures should be 
taken to diminish, as far as possible, the indescribable fetor or stench 
which surrounds him. This may be attempted by the administration 
of volatile antiseptics internally, and by the saturation of the surround- 
ing atmosphere with similar agents. Creasote, in doses of 2 to 5 
minims, in an emulsion or in capsular form, is the best. Turpentine, 
myrtol, oil of eucalyptus, or of peppermint, are also useful. Carbolic 
acid cannot be given internally for any considerable period of time 
with safety in doses sufficiently large for this purpose. Sulphocarbo- 
lates have been found to diminish the abominable odor from the 
perspiration. 

These volatile antiseptics, as they are excreted by the pulmonary or 
bronchial surface, afford the best chance of modifying the diseased 
action. 



LUNG, GANGRENE OF. 465 

The air of the room may be kept saturated with oil of turpentine. 
This may be accomplished by periodically pouring some of the oil 
upon the surface of very hot or boiling water ; but the rapid evapora- 
tion or vaporization of the turpentine soon ceases, as the temperature 
of the water falls. The writer's plan is to fill metallic trays or pans 
half full of dry pine sawdust, upon which the oil is to be freely 
sprinkled from time to time. A uniform degree of evaporation may 
be thus obtained. A good method, which he has also tried with satis- 
factory results, is to make a muslin or gauze coverlet, and fill it with 
freshly teased out oakum. This may be kept upon the patient's bed, 
and the oakum can be easily renewed, or sprinkled over with turpen- 
tine, eucalyptus oil, or other volatile antiseptic from time to time. 

Chloride of lime, bromine, chlorine, sulphurous acid, commercial 
terebene, sanitas, or any of the innumerable cheap disinfectants may 
be used for the same purpose. A spray apparatus may be employed 
to diffuse the disinfectant through the room. 

Of local remedies brought to bear upon the gangrenous region, any 
of the forms of antiseptic inhalations may be employed. Thus, the 
vapor arising from eucalyptus, menthol, iodine, chlorine, creasote, car- 
bolic acid, etc., may be breathed from any of the ordinary earthenware 
inhalers. As a rule, however, in an affection like the present, these 
are worthless. Where a very thorough disinfectant action is required, 
the volatile ingredient may be poured upon boiling water contained in 
a large wash basin, as the patient holds his head over it, while a linen 
sheet is thrown loosely over him, so as to extemporize a tent, under 
which the concentrated vapor may be freely breathed at intervals of a 
few hours during the day. 

It will not be found practicable to keep the atmosphere of the room 
impregnated with the vapor of the remedy to such a degree as to affect 
the secretions at the diseased spot in the lung, else no further inhala- 
tions or sprays would be necessary beyond the turpentine or other dis- 
infectant used to purify the air of the patient's chamber. It is thus 
essential that occasionally the remedies be employed in a more concen- 
trated form, as just mentioned, by steaming under a sheet. In the 
intervals between these steamings, he breathes day and night the more 
diluted medicated atmosphere of his room. 

Sprays are of considerable use, and are less troublesome, though of 
less efficacy, than the steaming under a sheet; by their use particles of 
a solution containing non-volatile ingredients may be projected in a 
state of minute subdivision, so that they may come into contact with 
putrefying secretions about the naso-pharynx, larynx, and larger air- 
tubes. The following solutions may be used as sprays : 

Bichloride of mercury, 1 to 2 grains in 10 ounces. 

Solutions of chlorinated soda, 1 in 20. 

Sulphurous acid, 1 in 20. 

Creasote or carbolic acid, 1 drachm in 10 ounces. 



466 LUNG, WOUNDS OF. 

Biniodide of mercury, 1 to 2 grains dissolved with potassium iodide, 

in 10 ounces water. 
Creolin, 1 to 2 per cent, solutions in water. 
By the use of Coghill's or any other small metallic inhaler, worn for 
a shorter or longer period during the day, many remedies may be 
brought into contact with the air-passages. In this way the following 
substances may be employed : Iodine, creasote, eucalyptus, carbolic 
acid, iodoform, thymol, menthol, etc. 

The following is a good inhaling fluid for sprinkling upon the lint 
or cotton wool of the inhaler : 

&. — Creasoti purif giij. 

Menthol ^ij. 

Thymol ^ss. 

Spt. vini rect. ad ^ iv. — M. 

S. — Use as directed. 

The expectoration should be passed directly into a spittoon, contain- 
ing some powerful disinfectant and deodorizer like turpentine, eucalyp- 
tus, chlorinated lime, or permanganate of potassium, in strong solution. 
It is only by rigid attention to these details that the abominable fetor 
can be so diminished as to permit the nurse and attendant to approach 
the patient closely. When the physical signs reveal a gangrenous ab- 
scess cavity, the operation of cutting down upon it, performing pneu- 
monotomy with the galvano-cautery or scalpel, evacuating its contents, 
blowing in a dry antiseptic pow 7 der, like boric acid, after washing it 
out most thoroughly with corrosive sublimate solution, and establishing 
free drainage, is the best procedure. 

LUNG, Hydatids of- See Hydatids. 

LUNG-, Inflammation of— See Pneumonia. 

LUNG, Passive Congestion of— See Treatment under Heart, 
Valvular Diseases of. 

LUNG, CEdema of. 

As this is secondary to valvular disease of the heart, or to Bright's 
disease, or merely as a local result of a general anasarca, its treatment 
will be detailed under the name of the primary affection. 

LUNG, Wounds of. 

The less interference in these cases, as a rule, the better ; the probing 
for bullets, etc., or examinations to determine the depth of the wound 
are unjustifiable. Perfect rest in an easy position with the patient 
lying upon the wounded side, and where there is much hemorrhage the 
insertion of good drainage-tube and the dressing of the wound with a 



LUPUS EKYTHEMATOSUS. 467 

large pad of carbolic gauze, fastened by a moderately tight broad 
bandage passed round the thorax, is all that is generally required. 

Complications as pneumonia, hremjthorax, pleuritis, • emphysema, 
empyema, acute bronchitis, etc., are to be treated upon the principles 
laid down under their several headings. 

LUPUS ERYTHEMATOSUS. 

While any departure from the healthy standard is to be carefully 
sought out and treated upon general principles, every means should be 
utilized whereby the general nutrition of the body is to be improved, 
and the general indications in this respect will be those mentioned 
under Scrofula, Phthisis, etc. 

Of internal remedies some have been reported as followed by com- 
plete and permanent cure, and the list of constitutional specifics for 
lupus erythematosus is not a small one. When it is remembered that 
in a not very small proportion of cases the affection disappears when 
left to itself, it can be readily seen that the apparent cures probably 
owe little to the remedy which has been employed. 

Of the remedies accredited with curative powers arsenic stands first, 
and since in small doses it may be given for long periods without doing 
any harm it may be employed in every case where there are no contra- 
indications. Some of the highest authorities have reported permanent 
improvements in a few cases as resulting from its prolonged adminis- 
tration, though the experience of every physician proves how useless it 
is in the vast majority of typical instances of the disease. 

Iodine (free) or iodides of iron, starch, or potassium, iodoform, car- 
bolic acid, phosphorus, minute doses of mercury, ergotine, iron prepa- 
rations, and last, though perhaps the only valuable member of the 
group, is cod-liver oil. Indeed, it will be a wise plan if this affection 
is to receive any chance of improvement from internal remedies to 
make a rule of giving the drug selected in combination or in conjunc- 
tion with cod-liver oil. (These remarks apply also to the treatment of 
true lupus, which is, however, even less likely to be benefited by con- 
stitutional remedies.) 

The local treatment of lupus erythematosus is a difficult subject 
in the limited space of a short article like the present, especially as a 
survey of its literature would almost lead one to conclude that nearly 
every known inorganic remedy had been recommended for its destruc- 
tion at some time or other. This is the more remarkable as the 
affection is a comparatively rare one. 

Another inherent difficulty, apart from the extraordinary multi- 
plicity of so-called remedies, is the task of giving a clear idea of the 
agents indicated at the different stages and variations of the disease 
without a minute description of these stages, which vary in almost 
every instance. These remarks apply with more or less truth to the 
treatment of true lupus also. As stated by Pye-Smith the treatment 
of erythematous lupus is that of the milder forms of lupus vulgaris, 



468 LUPUS EKTTHEMATOSUS. 

stimulating applications generally taking the place of destructive 
measures. 

In the early or erythematous stage, soothing lotions or ointments are 
indicated to relieve congestion and pain. Speaking generally, cases at 
this period of the disease may receive the treatment most useful in 
acute eczema. Thus a bland, unirritating ointment, such as the ungt. 
zinci oxid., to which liq. plumbi subacetat. (1 : 20) is added, or a cream 
or paste made by rubbing up the oxide of zinc with olive oil, may be 
smeared over the parts with a brush several times a day. A weak lead 
lotion (1 : 20), lime-water, or carbolic lotion (1 : 40) may be applied 
under oiled silk. 

In the acute stage, when the disease is active or spreading, and the 
skin hot and sensitive, most agents do harm. Duhring then recom- 
mends the following application with the view of controlling the active 
hypersemia : 

J& . — Potassii sulphidi . . .' . . . . gr. v. 
Zinci sulphatis . . . • . . . gr. v. 

Spt. vini rect ^ ss. 

Aquae dest . ^ iv. — M. 

S. — To be applied as a wash to the affected parts by dabbing on lightly, for 
fifteen or twenty minutes, three times a day. 

The quantities of the first two ingredients may be increased from 5 
to 20 grains as the hyperemia subsides. 

Collodion painted constantly over the part and permitted to dry 
causes compression of the vessels, and, provided one layer be added 
before the cracking or peeling of the former one renders its action void, 
a continuous action may be kept up which, with great care and 
patience, may prove valuable. It protects the parts from changes of 
temperature, and, by the compression of the tissue, may promote the 
absorption of effused products, or starve out the small-celled growth 
in the connective tissue. 

At a later stage stimulating applications may be tried, but in this 
sometimes a difficulty presents itself, one part of the patch being dis- 
tinctly erythematous, while the other shows infiltration or scarring. 
Tarry compounds are very valuable, and, if persisted in at this stage, 
may give good results. The most suitable is an ointment varying in 
strength from half to two drachms of the liquor carbonis detergens to 
1 ounce of lanolin. When this fails the next best method of treatment 
will consist in the application of the unguentum hydrargyri, or a 10 
per cent, ointment of the oleate of mercury upon lint, which should 
be kept in contact with the part constantly. 

An ointment like the following may be used where there is much 
redness or irritation present : 



LUPUS VULGARIS. 469 

R . — Liq. plumbi subacetat. TTtxxx. 

Liq. carb. deterg. 3j. 

Pulv. camphorse £ss. 

Ungt. aquse rosae ^ij. — M. 

S. — To be constantly smeared over the affected area. 

Carbolic acid, in the form of an ointment (1 : 10), may be applied, 
and when at a later stage it is decided to destroy the growth, the acid 
may be painted on in its purity. Naphthol, chrysophanic or pyrogallic 
acid, resorcin, strong iodine solutions or ointments, mercurial plaster as 
strongly recommended by Kaposi, green or soft soap, sulphur ointment, 
iodine as tincture, ointment, or glycerin, Fowler's solution brushed on 
daily, or 10 per cent, ichthyol ointment, may be tried. 

Where absorbent or stimulating applications fail, and the disease 
continues to progress, the destruction of the new growth by stronger 
remedies is to be seriously considered, and much caution and some skill 
is requisite in carrying out this in order to prevent such a free destruc- 
tion of tissue as may result in a more unsightly appearance than if the 
affection was left to itself. 

Any of the caustics recommended for the destruction of tissue in 
lupus vulgaris may be tried. Thus creasote, salicylic, carbolic, acetic, 
or lactic acids, chloride of zinc, solid nitrate of silver, permanganate of 
potassium, corrosive sublimate, nitrate of mercury solution, or surgical 
procedure with the spoon, cautery, or galvano-cautery may be resorted 
to. 

The safest and least disfiguring method of treatment is that by 
linear multiple incisions or scarifications made by a suitable instru- 
ment. With great care these incisions may be made with the point of 
a fine, very sharp scalpel or tenotomy knife, so as to leave the healthy 
skin untouched, as practised by Shoemaker. The object of these 
minute incisions or punctures is to cause destruction of new vessels, 
and so starve out the growth and cause its absorption. The punctures 
should not exceed one-fifth inch in depth, and they should be as close 
together as possible. 

LUPUS VULGARIS. 

The same advice regarding the treatment of any diseased organs 
and the management of any deviations from the standard of health, 
as given under Lupus Erythematosus, may be followed. 

As for constitutional remedies or internal specifics, there are none. 
Nevertheless, the same drugs which have been supposed to exert a 
specific action in the erythematous variety of lupus may receive a fair 
trial. These are cod-liver oil, arsenic, phosphorus, iodine, iodoform, 
mercury in very small doses, and the various preparations of iron. 

Hutchinson lays great stress upon the importance of constitutional 
treatment directed to improving the general health, and to the necessity 
of protecting the seat of the disease from cold and damp in winter. He 



470 LUPUS VULGARIS. 

therefore recommends the lupus patient to keep in warm rooms in the 
winter, or to change his residence so as to enjoy perpetual summer. To 
the writer it seems that much may be expected by the exhibition of 
improved hygienic agents, which are likely to put the tissues in a better 
position for permitting phagocytosis — Nature's remedy — to take place. 
(See under Tuberculosis.) 

Local treatment is varied by each specialist who has his favorite 
remedy. Before ulceration has set in some recommend soothing appli- 
cations, as zinc ointment, lead lotions, etc., as in the erythematous 
variety, but no hope need be indulged in that such 'measures can do 
anything but give very temporary relief. They are necessary, however, 
in various stages of the advanced disease, in order to subdue the 
smarting and congestion which hover about the circumferential zone 
of the affected patches. 

Various remedial agents have been used with the view of stimulating 
the unulcerated spots, so as to promote absorption without injuring the 
skin. Failure is the general result, though in many cases the disease 
may be checked or held at bay by this means for considerable periods. 

Vidal rubs in the oil of anacardium. The ointment, oleate, or plas- 
ter of mercury, iodine applications, tar ointments, and the various 
stimulating applications mentioned under lupus erythematosus have 
been tried. Ice applied for two or three hours daily has been used 
with the view of killing the bacillus, which is now demonstrated to be 
the cause of the disease. 

Where ulceration has taken place there is little use in wasting time 
with treatment which at the best can only be palliative. The new 
growth must be effectually destroyed, and tubercles or nodules escap- 
ing the destructive process act as infective centres and cause return of 
the disease. 

The depth, extent, rate of progress, duration, and situation of the 
diseased action will require different modifications in the various 
methods by which the destruction is to be accomplished. 

Great activity, apart from the trial of Koch's lymph, has been evi- 
denced in this little corner of the therapeutic field of late, and the 
result has been the introduction of quite a number of methods, for 
which is claimed that by their use the diseased elements of the skin are 
effectually destroyed without the least injury to the healthy constitu- 
ents of this tissue. The great object being the destruction of the dis- 
eased cell-growth, this can be more easily, rapidly, and certainly 
accomplished by surgical methods ; but as the chief site of the affection 
is upon the face, the nature and extent of the resulting scar is a matter 
of the greatest moment to the patient. Hence any agent which will 
select out the new growth and accomplish its annihilation with the 
minimum loss of healthy tissue will be of the greastest value, even 
though the process be a tedious one. These agents are, however, 
sometimes uncertain in their action, especially where the disease is 
extensive ; but they are often very successful in dealing with small 



LUPUS VULGARIS. 471 

patches, aud, though the operator need not expect to get the speedy 
and complete triumph which a perusal of the recent literature of lupus 
would lead him to believe is awaiting a trial of these remedies upon 
the first case which he meets, nevertheless, in the great majority of 
instances, ultimate success will follow a steady persevering application 
of most of the members of this class. 

The most typical member of the group is salicylic acid. It is best 
used as a paste, which can be made by rubbing up the pure acid with 
creasote in about equal proportions. Where an extensive ulcerated 
surface upon the face is to be operated upon with this paste, the ulcers 
should be previously freely brushed over or covered with a piece of 
lint soaked in a strong solution of cocaine (10 to 20 per cent.). The 
paste can then be applied daily until a raw granulating surface is seen 
to occupy each spot where tubercles or ulcers had formerly flourished. 

Unna's " plaster mulls," containing salicylic acid and creasote, are 
much more elegant and efficacious agents. The ointment form is pre- 
ferred. The following is a good formula ; it should be spread on lint 
and covered with gutta-percha : Creasote, 2 drachms ; salicylic acid, 1 
drachm ; and simple ointment, 2 drachms. 

No rule can be laid down for the number of applications. The 
physician should not begin the treatment unless he has made up his 
mind to the trouble and slowness of the process. The writer has seen 
a considerable patch treated by this method get perfectly healed up 
inside three months. Whatever objections may be made upon the 
score of delay are often answered by the slight and satisfactory nature 
of the resulting scar. As will be mentioned later on, this paste is of 
unquestionable value in very obstinate cases, when applied after surgi- 
cal measures have been employed to remove the diseased tissue in 
bulk. 

Lactic acid is another remedy which there is good reason for be- 
lieving may cause destruction of the diseased cell growth without in- 
juring the healthy skin. The concentrated acid only should be used, 
and, owing to its thick, syrupy consistence, there is not any great 
difficulty in limiting its action to a particular spot. The writer has 
used it a considerable number of times, and can to a certain degree 
corroborate the statement made by Hortmann, who says : " It seeks out 
the diseased tissue — as a dog does game — surely finds it and effectually 
destroys it ;" but occasionally, perhaps, when the game is scarce, it 
appears to prey, in the writer's opinion, upon the margin of the healthy 
skin, and hence it requires some watching. 

It may be used in various forms, and that of a paste, consisting of 
about equal quantities of the syrupy acid and kaolin, is the method 
most recommended. It is also painted on with a brush or injected 
hypodermically (1 : 2) into the tissue in the diseased area. The sim- 
plest method by far which the writer devises, and from which he has 
never seen any ill effects, is the following : After previous poulticing 
and ablution, paint the ulcerated surface over with a 15 per cent. 



472 LUPUS VULGARIS. 

cocaine solution several times before applying the acid, and wipe it 
quite dry with absorbent wool immediately before the acid is brought 
into contact with it. Make a little map of the ulcerated surface, so as 
to cut out neatly and accurately a folded piece of lint (two plies) of the 
same size and shape as the patch. These should be soaked for some 
minutes in the pure concentrated acid placed in a saucer, the surplus 
acid being very gently removed by the least squeezing out. The double 
layer of liut may be accurately applied to the diseased surface by 
means of dressing forceps. 

The margins of healthy skin may be smeared over with any firm 
cerate to prevent the acid trickling over the face. The pain is often 
severe, and lasts some hours. The lint may be covered with oiled 
silk, but the writer does not do so. He applies some more acid to it 
with a brush after a few hours, without disturbing its position. It may 
be left in contact for about four hours. Authorities differ, some direct- 
ing an application of fifteen minutes, and others recommending one of 
ten hours, after which spirit lotion on lint may be applied under oiled 
silk. The number of applications required in any given case can only 
be determined by the effect. After three or four days the surface 
should be very minutely examined, and any suspicious portions sub- 
jected from time to time to the action of the acid, applied upon little 
circular islands of lint for six, eight, or ten hours. The treatment 
will extend over several weeks or months, and as parts of the original 
patch become entirely healed, others probably may be discovered in 
which the diseased action is in full swing. Thus destruction and 
repair will be carried on at the same time in different regions of the 
same patch. 

It will thus be seen that the management of true lupus by this 
method is most tedious, and makes severe demands upon the time and 
patience of the physician, but just as he begins to feel that he or the 
patient may be carried off by old age or some concurrent malady 
before the diseased patch has been all replaced by healthy, transparent 
cicatricial tissue, he will probably be rewarded with a clean, smooth 
scar, showing no vestige of "apple-jelly" blossoms, and presenting the 
minimum of deformity. 

Pyrogallic acid is stated to possess some selective affinity for the new 
growth, and is applied in the form of an ointment (1 : 8), as a plaster 
(1 : 5), or brushed on as a saturated solution in ether ; but its destruc- 
tive powers are by no means so easily controlled as those of salicylic 
or lactic acids. 

Arsenic, applied in the form of Fowler's solution, is stated to cause 
the destruction of the new growth without injury to healthy skin. It 
should be applied daily until it causes severe inflammatory swelling, when 
its use is to be suspended for a time. Heller employs this method of 
dealing with both true and erythematous lupus, and speaks highly of 
the results. Arsenic in more concentrated form is also used as a caustic, 
as will be presently mentioned. Some specialists have reported very 



LUPUS VULGARIS. 473 

favorably of the injection of Fowler's solution into the diseased region 
and its margins. 

Hydroxylamin, a powerful reducing agent, has been successfully 
used as a local remedy in lupus, beginning with an alcoholic solution 
(1 : 1000) painted over the cleansed ulcers four times a day. Eichhoff 
increases the strength of the solution gradually until double or treble 
the above percentage is used, without producing secondary inflam- 
mation. 

Peru balsam is recommended as a local application twice a day in 
very mild cases, and as a preliminary measure in severe cases requiring 
surgical operation. 

Caustics or corrosives are employed in the treatment of lupus with 
the view of causing the destruction of the diseased tissue in bulk. 
Nearly every known chemical substance capable of accomplishing the 
death of healthy tissue has been used for this purpose. Nevertheless, 
this method of treatment will probably soon cease to be practised, 
owing to the difficulties in limiting the destructive action to the dis- 
eased area. From their use speedy and radical cure of the disease 
may be obtained, but the scars are often most unsightly. If too little 
depth of tissue be destroyed, the resulting useless irritation may hasten 
the growth of the new cell formation, and cause the roots of the disease 
to strike deeper into the soil. If too much or too great a depth of 
tissue be removed, the resulting scar will be proportionate. The only 
way in which these remedies can be safely used is by the specialist, 
who, confining himself to the employment of one or two members of 
the group, will soon acquire a thorough and complete mastery over his 
weapon when directed against the endless variations of lupoid growths. 
It is surprising to see how satisfactory are the results obtained upon 
this principle by quacks, who confine their attention and practice to 
the removal of epithelial and other cancers and lupus, though it must 
be remembered that pride and other motives tempt their patients to 
hide the failures. 

The recent improvements in the surgical or mechanical methods of 
treating lupus will still more likely cause this group of remedies to 
fall into disuse, or to be merely confined to the superficial layer of 
tissue left after the knife or cautery. 

Kaposi applies for twenty-four hours a paste composed of chloride 
of zinc and butter of antimony in equal quantities, with half as much 
strong hydrochloric acid, mixed with the same amount of liquorice 
powder. The following are also used, viz. : 

Vienna paste, made by mixing caustic potash with rather more than 
its own weight of water, and adding a little rectified spirit. 

London paste, made by mixing caustic soda with an equal weight of 
recently burned lime, and adding a sufficient amount of rectified 
spirit. 

Hebra's paste of arsenic, composed of — 

31 



474 LUPUS VULGARIS. 

R . — Acid, arseiiios. gr. xv. 

Hydrarg. sulph. rub. ...... gr. xlv. 

Unguent, cetacei gvj. — M. 

S. — To be used as directed. 

Iodine paste or cream, prepared by triturating equal quantities of 
pure metallic iodine and tincture of iodine together, and adding to the 
mixture an equal amount of glycerin. 

Nitrate of silver is still often used. It was a favorite remedy of 
Hebra. It may be used as a solution (60 grains to 1 ounce), or as the 
solid stick which is better. This may be thrust into the papular or 
tubercular elevations, and though terribly painful, is very efficacious 
when thoroughly and persistently applied. The pointed stick of 
caustic may be thrust into each lupus nodule after puncturing it with 
a lancet. 

Acid nitrate of mercury is an excellent and manageable caustic 
which the writer has used always with great satisfaction when the 
disease is very superficial, and limited in extent. It may be applied 
daily upon cotton wool twisted around a probe, or by means of a brush. 

Carbolic acid, the solid acid liquefied by heat, may be applied every 
day after drying of the surface; its action is, however, very super- 
ficial, and in many cases it does not reach the diseased stratum at all. 
Sprays of various strengths of the drug have been used, but with very 
poor results. 

Nitric acid, in concentrated form, may be tried by means of a glass 
brush or wooden spatula, but it is open to the same objections as the 
last-mentioned agent. 

Permanganate of potassium, in solution (1 : 10), may be painted 
daily until the nodules are destroyed. 

Chromic acid has been recommended, but it is a treacherous caustic 
for the face. It may be used when the mucous membrane has become 
affected. 

Iodide of sulphur (1 drachm to 1 ounce), in the form of ointment, 
is recommended, but it produces pain and inflammation out of propor- 
tion to the good which it does, 

Ethylate of sodium solution is an excellent caustic where there is 
little tissue calling for destruction. The B. P. solution may be daily 
brushed over the diseased patch (which should be dried with blotting- 
paper), by means of a glass brush until a scab forms, which falls off in 
a few days, after which the applications are to be renewed. If pain is 
severe, a drop of chloroform may be applied. This converts the ethy- 
late into ether and chloride of sodium. The scarring is comparatively 
slight. 

Bichloride of mercury has been used in various forms and in 
solutions of various strengths, from the 2 grains per ounce, which is 
rubbed on with the view of preventing the growth of the bacilli, to 
the 20 grains per ounce solution in alcohol, which is employed with 



LUPUS VULGARIS. 475 

the view of destroying the tissue. Unna's method of using this agent 
as an auxiliary to treatment by surgical or salicylic processes, is a very 
important step in the problem of treating lupus. After dealing with 
the disease in bulk by the more radical measures, it is found that 
scattered nodules, about the margin of the sore, remain undestroyed, 
and give much trouble. For these the following solution is recom- 
mended : 

R . — Hydrarg. bichlor 3J- 

Creasoti purif. ^ ss. 

Alcoholis purif. ad ^iij. — M. 

S. — To be used as directed. 

At each sitting, about ten lupus marginal nodules are to be selected 
for destruction. By a fine acne lancet each is punctured, and the 
above solution applied on a little absorbent wool, mounted upon a bit 
of match-wood. The moistened wool should be thrust down deeply 
into the punctured nodule and left in situ for fifteen or twenty 
minutes after the wood is withdrawn. In a few days the punctured 
wound and lupus nodule have disappeared. The process is a slow 
one, but if a different region of the face be operated upon every day 
it is surprising how soon these scattered nodules may be cleared away. 

In a similar manner, iodine in solution has been injected for this 
purpose by a fine syringe into the nodules. Twenty grains of iodine 
are dissolved in 1 ounce of glycerin. 

Shoemaker has caused the destruction of the diseased tissue by estab- 
lishing the jequirity inflammation, and Townseud has produced a simi- 
lar result by the application of Alveloz. Both these methods are open 
to serious objections, the chief of which is the difficulty in limiting or 
circumscribing their action when once it has been set going; and, 
moreover, they may leave as a legacy, even when successful, deep and 
unsightly scars and deformities. 

As preliminary to operative measures, and in some cases as a substi- 
tute for them, Brooke recommends the slow, prolonged, steady friction 
of an ointment consisting of 15 grains of salicylic acid, 15 grains of 
ichthyol, and 1 ounce of oleate of mercury (21 to 5 per cent.). 

The mechanical or surgical methods of treating lupus afford the 
most rapid and thorough results, but the scar is often more disfiguring 
than that left by lactic acid or by the paste of salicylic acid and 
creasote. With moderate care, however, the scars need not be more 
extensive than those produced by these remedies. Mechanical treat- 
ment, moreover, is the only available method left in very severe cases, 
and since the deformity can be minimized by various procedures in 
the after-treatment, this method gives, upon the whole, the most satis- 
factory results, and is daily becoming more thoroughly recognized as 
the treatment for lupus vulgaris. 

The mechanical methods consist of: 



476 LUPUS VULGARIS. 

1 . Multiple puncturing or scarification. 

2. Scraping or curetting by Volkmann's spoon, or the sharp 
curette. 

3. The thermo- cautery of Paquelin. 

4. The galvano-cautery, or the actual cautery. 

5. The destruction of the tissue by Morris's double-screw, or a den- 
tist's burr. 

6. Excision of the diseased tissue by the knife. 

7. Any of these methods combined. 

8. Any of these methods followed immediately afterward by 
caustics. 

9. The process of electrolysis, originally introduced by Gartner and 
Lustgarten. This method has never obtained the full trial which 
it merits. In the hands of Jackson it has given good results. He 
uses a button electrode for large surfaces, and a course sewing needle 
for small ones, and the strength of the current in the former case is 
seven milliamperes, and in the latter about three. He reports that the 
electrolytic action of the current seems to expend itself only upon the 
diseased tissue. 

The most satisfactory and radical of all these procedures is carried 
out by chloroforming the patient and scraping the diseased surface 
with Volkmann's spoon until a healthy layer, free from all lupoid 
nodules, is reached. Unna prefers Paquelin's cautery to the spoon for 
this purpose. 

Before the influence of the anaesthetic has passed off, the scraped 
or burned surface is rubbed with the following solution — i. e., carbolic 
acid, 1 drachm; bichloride of mercury, 1 scruple; spirit of ether, 1 
ounce. A plaster containing 20 grammes of salicylic acid and 40 
grammes of creasote, or guaiacol 10 grammes and salicylic acid 20 
grammes per one-fifth part of a square metre, is applied, and covered 
over with glycerin jelly and cotton wool. 

In twenty-four hours Unna removes the dressing, cleanses the sur- 
face, paints with cocaine, and rubs or bores all suspicious-looking spots 
with a 10 per cent, sublimate pencil, and redresses with the plaster. 
Where the plaster is not obtainable and where chloroform cannot be 
given, and where the knife or cautery is objected to, he resorts to the 
chemical method, and applies in the first instance a strong ointment of 
1 part salicylic acid, 2 parts creasote, and 2 parts simple ointment. 
The strength of the plasters and ointment should decrease as the treat- 
ment progresses. 

Schiitz attaches great importance to the free application of collodion 
over the dressings in order to cause compression upon the granulations 
and prevent retraction of cicatricial tissue, so as to leave the best pos- 
sible scar. Lassar also lays great stress upon the constant inspection 
of the wound and the repression of granulation tissue until a genuine 
epidermic formation is established. 

Hebra's new dressing may be applied after the destruction of the 



LYMPHADENITIS. 477 

growth. He has also obtained good results from its use where no 
scraping or other operation has been performed. It is known as 
"creasote salicylic glycerinum saponatum," and contains 5 per cent, of 
creasote, 5 per cent, of salicylic acid, and 90 per cent, of glycerinum 
saponatum. (See page 231.) 

Eichhoff extols the use of aristol as a dressing. It is a derivative of 
thymol, and, while more active than iodoform, is is perfectly harmless 
and odorless. 

Barling advises, when possible, the excision of the diseased tissue, 
including the entire depth of the skin and its subcutaneous fatty layer, 
and the repair of the breach by a plastic operation. Skin grafting has 
given good results in such cases. Excision is certainly the most satis- 
factory of all treatments when the lupus is not upon the face, but upon 
some part of the body covered by the dress. 

The treatment of lupus by Koch's lymph has recently attracted the 
deepest interest, and at the present moment the most eminent authori- 
ties deny that a single absolute cure has been seen. Nevertheless, it 
is highly probable that, combined with surgical procedures —scraping, 
etc. — a very distinct advance in the treatment of this disease will 
be established. (See under Tuberculosis for full details of Koch's 
plan and for suggestions from the writer for a new method of using 
the agent.) 

The hypodermic injection of dog's serum, as recommended by Pro- 
fessor Richet, has already given excellent results, which the writer has 
witnessed in the wards of Professor Fournier, but the permanence of 
the effects is not yet established. 

LYMPHADENITIS. 

In simple acute inflammation of lymphatic glands occurring in 
healthy individuals, the first indication is to treat the cause. As this 
in most instances will be found to be the absorption of some septic 
product originating in a wound or abrasion upon the distal side of the 
gland, the condition of the wound or focus of infection will require 
attention. Antiseptic dressings should be applied under oiled silk, 
and if any pus has formed in its immediate vicinity it should be at 
once evacuated. As there is generally acute inflammation (lymphan- 
gitis) of the lymphatic vessels between the wound and the inflamed 
gland, the band or strip of skin should be painted over with the 
tincture of iodine, which often acts like a charm in reducing the 
lymphatic irritation. Rest to all the parts (muscles, joints, etc.) in 
the neighborhood of the inflamed gland must be secured. 

The constitutional treatment should be directed to the reduction of 
fever and relief of pain, a smart saline purgative, followed by small 
doses of aconite, and a milk or fever diet being administered. In 
septic cases, or those following poisoned wounds, a liberal nutritious 
diet, with alcoholic stimulants and concentrated beef extracts or soups 



478 LYMPHADEKITIS. 

may be commenced as soon as the first acute symptoms have been 
combated. Basham's mixture, or large doses of the tincture of iron, 
alternating with full doses of quinine, afford the best internal treat- 
ment. 

The following may be given with advantage : 

JR. — Sodii sulphocarb 3ij. 

Glycerini ... r ..... ^ss. 
Tract, aurantii amar. . . . . . 5jss. 

Aquae camph ad ^yj. — M. 

S. — One tablespoonful to be taken in two tablespoonfuls of water every three 
hours. 

Local treatment should consist in measures likely to relieve tension 
and check inflammatory action in the gland. 

Cold or hot applications have each their advocates, and the same 
result — i. e., resolution without suppuration — may be secured by both. 
By ice, evaporating lotions, cold compresses, or Leiter's tubes the ten- 
sion and arterial supply are soon markedly lessened, and the inflam- 
mation as evidenced by pain, heat, redness, and swelling soon dimin- 
ishes or disappears. When hot or warm compresses or poultices are 
applied, as shown by Brunton, the capillaries of the collateral circula- 
tion are dilated and the current is diverted from the inflamed vessels. 
Up to a certain point both methods of treatment tend to prevent sup- 
puration ; and the writer has satisfied himself that, contrary to the 
popular notion, warm poultices prevent suppuration by reducing the 
tension of an inflamed gland if applied at an early stage, the general 
relaxation of the tissues sometimes speedily relieving the tension which 
is fatal to the life of the organ. 

At a later stage, by keeping up a continuous moist warmth and 
making the part an internal one, poultices hasten the pointing of the 
abscess. 

Nasiloff treats inflamed glands by using compresses at a very high 
temperature. He drops several piles of linen into boiling water, 
squeezes them out quickly, and applies them directly over the inflamed 
gland and envelopes the part for fifteen minutes in a thick pad of 
cotton wool. 

The best guide to the selection of hot or cold applications is the sen- 
sation of comfort or pain produced, the applications from which the 
patient derives the greatest ease being always preferred. 

Spirit lotion (1 : 3) applied upon lint and covered with oiled silk is 
one of the best possible local applications. If gently warmed before 
coming into contact with the skin, and if a thick layer of cotton wool 
be lightly bandaged upon the top of the oiled silk, an antiseptic poul- 
tice of the highest merit is thus obtained. 

Various abortive treatments are employed, with the view of cutting 
short the inflammation and preventing suppuration, and several 



LYMPHADENITIS. 479 

counter-irritants are recommended for this purpose. The writer has 
obtained most satisfactory results from freely painting the skin over 
the inflamed gland with iodized phenol (1 ounce iodine rubbed up with 
4 ounces of warm carbolic acid). Solid nitrate of silver is rubbed upon 
the previously moistened skin by some, others brush over a strong solu- 
tion of it. 

Iodine, carbolic acid, collodion, bichloride or nitrate of mercury 
solution, and other substances, are painted over the integument under 
which the infected gland lies; Blistering is also resorted to ; but it is 
most objectionable in acute cases. It has been tried to prevent suppu- 
ration by injecting a few drops of liquid carbolic acid into the in- 
flamed gland. 

Rubbing in of liniments or friction in any form is almost certain to 
determine the formation of matter. The actual or Paquelin's cautery 
lightly passed over the skin occasionally appears to retard or prevent 
suppuration. (See also under Bubo and Boils.) 

When pus has evidently formed in the gland its speedy evacuation 
should be accomplished. Aspiration is worse than useless, and the 
plan of making a punctured wound and squeezing out the matter is 
objectionable. 

The old-fashioned free incision is the best, and unless there be much 
pain and increased tension a poultice had better not be applied. 
Warm spirit lotion under oiled silk is a comfortable antiseptic for small 
abscesses of this sort. 

In the majority of instances the free incision does away with the 
necessity of a drainage-tube. A small wound is of much advantage 
if the scar is visible, and where the adenitis follows some irritation 
about the jaws the incision should be as limited as possible, compatible 
with evacuation, and a fine drainage-tube or a few shreds of carbolized 
tow or horse-hair w T ill establish the removal of all pus as it is secreted. 
(See under Abscess for the various recent methods of dealing with local 
collections of pus.) After the free removal of pus and the application 
of spirit lotion under oiled silk, the cavity may be syringed out with 
weak sublimate solution (1 : 3000) from time to time as it heals up 
from the bottom. 

In chronic cases it is equally necessary to find out and treat the 
primary focus of infection, after which the gland enlargement, if pus 
has not formed already, may be subjected to mild counter-irritation 
or friction with a stimulating absorbent. The tincture of iodine is 
often of some service ; but the writer uses the lin. potas. iod. cum 
sapone, B. P. Belladonna plaster or the iodide of lead plaster may 
be applied over the tumor. Where the enlargement remains, and 
suppuration does not take place, this latter result may be brought 
about by the injection of various irritants, when to allow the gland to 
remain in its enlarged condition would be to keep up an eye- sore. 
Carbolic acid, iodine, acetic acid, chlorides of iron, and mercury, etc., 
have been injected. 



480 LYMPHADEKOMA. 

Treves in such cases thrusts the finest point of the ther mo-cautery 
through the skin, and moves it about inside the gland, in order to 
break up and cause disintegration of its tissue, after which he inserts 
a fine drainage-tube and applies poultices. 

Sinuses should be slit up and scraped, and permitted to heal from 
the bottom, and where glands cannot be reduced in size by the above 
treatment, or where the suppurative process only destroys a portion of 
their tissue, they may be carefully dissected out. The writer success- 
fully dissected out a mass of chronically enlarged glands below the 
groin, in the interior of which a large calcareous deposit had formed, 
and which had been supposed for years to be a case of disease of the 
upper end of the femur. A probe passed into any of the numerous 
sinuses always struck on what felt like diseased bone. Rapid healing, 
with trivial cicatrix, resulted. 

Scrofulous affection of lymphatic glands will be mentioned under 
Scrofula. 

LYMPHADENOMA. 

The only treatment for a simple hypertrophy of solitary lymphatic 
glands is removal by the knife. Considering that there is good ground 
for believing that a solitary adenoma may be the starting point of the 
disease, known as Hodgkin's Disease, the early removal of the growth 
is strongly indicated when there is no reason to believe that it is of a 
purely scrofulous nature. Even when several contiguous glands are 
markedly enlarged without any increase in the size of the lymphatic 
glands throughout the body and without splenic disease, and in the 
absence of considerable increase of white corpuscles in the blood, the 
operation should not long be delayed. 

When the constitutional features of the mischief, known as non- 
leuksemic lymphadenoma or Hodgkin's Disease, have become estab- 
lished, extirpation of the tumors is much worse than useless. All that 
can be hoped in such cases is that by attention to health through im- 
proved feeding, change of residence to a healthy seaside resort, and 
the employment of every means by which digestion and appetite can 
be improved, that the disease may be retarded in its progress by the 
administration of special remedies. 

Arsenic in very large doses has been found in some isolated cases to 
cause disappearance of the glandular enlargements and restoration to 
health. This occurred in one patient under the care of Billroth. Many 
observers have, however, reported that marked improvement for a time 
has followed the use of arsenic, and sometimes there is good ground 
for believing that the invariably fatal progress of the malady has been 
held in check for considerable periods by its steady administration. It 
may be given in combination with iron, for although this drug appears 
to have no effect upon the anaemia present in the fully established dis- 
ease, it appears to materially increase the beneficial action of arsenic. 
Fowler's solution should be commenced in doses of 5 minims, and in- 



LYMPHANGITIS OR ANGEIOLEUCITIS. 481 

creased until 15 minims, three or four times a day, are administered 
immediately after food. Larger doses have been given without pro- 
ducing any ill effects. The remedy has been injected with a fine 
needle into the enlarged glands, but it is doubtful if this is of any 
use. Where it causes irritation in the stomach and bowels, the 
hypodermic method of injecting 5 minims diluted with one or two 
drachms of water into the areolar tissue may be resorted to. 

The other remedies believed to be of some use in this disease are 
phosphorus, iodide of potassium, and cod-liver oil. Where arsenic and 
iron cannot be well tolerated or when they fail, phosphorus may be 
tried in conjunction with cod -liver oil. The phosphide of zinc has 
been resorted to by Keclus and others with some apparent benefit, but 
as arsenic had been always previously employed in the cases reported, 
>it may have been the cause of the temporary improvement. Mercury 
should not be given. Of local remedies or methods all have proved 
unsatisfactory. The excision of the glandular tumors and the injec- 
tion of arsenic into them have been already referred to as highly 
unsatisfactory, the same may be said of galvano-puncture, the in- 
jection of carbolic acid, iodine, chromic acid, and various other 
irritants. 

LYMPHANGITIS OR ANGEIOLEUCITIS. 

Where the chief trouble appears to be centred in the lymphatic 
vessels the same principles are to be recognized in the management of 
the case, as have already been detailed in speaking of the treatment of 
inflamed lymphatic glands under Lymphadentitis. Thus attention 
should be at once directed to any injury or wound which has been 
the starting point of the affection. This should be treated by anti- 
septic poultices (spirit or carbolic lotion, under oiled silk), and the 
free evacuation of any collections of pus by proper incisions. Where 
the lymphangitis is superficial, and the red, tender, painful, and 
swollen lymphatic vessels can be discerned extending from the wound 
in the direction of the lymphatic glands, the greatest good can be got 
by painting over the inflamed area with the tincture of iodine, and 
prescribing absolute rest to the affected limb. 

In six or eight hours an evaporating lotion or a warm spirit lotion 
may be applied. Where tension and pain are prominent, a large hot 
poultice may afford relief and even diminish the chance of suppuration. 
Pus should be evacuated as soon as it is found to be present, and 
antiseptic dressings applied warm. 

Saline purgatives, iron, quinine, and stimulants, with pure air and 
wholesome plain food such as milk and eggs, in abundance, are all 
that are generally found needful. 

MALARIA— See Intermittent Fever. 

MALIGNANT DISEASE— See Cancer. 



482 MAMMARY GLAND, INFLAMMATION OF. 

MALIGNANT PUSTULE OR WOOLSORTERS' DISEASE. 

In the external form of the disease, as soon as the nature of the local 
eschar justifies a decided diagnosis, active surgical treatment should be 
commenced without delay. This consists in the removal or destruction 
of the eschar or so-called pustule, and the success of the procedure in 
preventing or minimising constitutional infection depends upon its 
early and prompt adoption. After excising the diseased tissue with a 
sharp scalpel, the galvano-cautery should be applied freely to the 
wound. 

Where the pustule is very small, it may be treated as a carbuncle, 
by making a free crucial incision, and applying a strong caustic-like 
potassa fussa, chloride of zinc, strong nitric acid, or nitrate of mercury. 
Some authorities inject tincture of iodine or strong carbolic acid into 
the centre of the eschar, and into the tissues around its base. 

There cannot be any question of the relative merits of these opera- 
tions. The complete excision by the knife and the after-application of 
the cautery should always be preferred, even when the constitutional 
symptoms have become well marked. The wound may receive one or 
two dressings with a paste made by rubbing up quinine with spirit of 
turpentine. The paste has been used by Rivas with success in several 
cases as a local method of dealing with the eschar without previous 
excision. 

Where there is constitutional disturbance, showing that general in- 
oculation has already occurred, or whore the internal form of the dis- 
ease is present without any eschar, the treatment must be as supporting 
as possible. Concentrated beef essences and highly nutritious soups or 
strong beef or mutton broth, and free stimulation should be resorted 
to from the beginning. Quinine, sulphocarbolates, sulphites, carbolic 
acid, salicylates, and large doses of the chloride of iron in combination 
with mindererus spirit, may be given. Where pulmonary mischief has 
resulted from direct inhalation of the poison without eschars, the best 
chance will be given by surrounding the patient with an atmosphere 
saturated with eucalyptus, carbolic acid, or turpentine. The various 
complications, as pleuritic effusion, oedema of the glottis, hemorrhages, 
etc., must be dealt with upon ordinary therapeutic principles. 

MAMMARY GLAND, Inflammation of, or MASTITIS. 

Preventive treatment directed to the nipple (see Nipple) during the 
latter days of pregnancy and after delivery, materially diminishes the 
chance of mastitis. Where the gland becomes swollen and painful, 
rest is the first indication. This is obtained by keeping the patient 
upon her back, with the breast supported by a sling or broad bandage 
passed under the dependent gland and over the opposite shoulder. 
The arm should be kept close to the side, but, as a rule, this can be 
managed by the patient without bandaging. The question of putting 
the infant to the swollen gland can only be decided by experiment. It 



MAMMARY GLAND, INFLAMMATION OF. 483 

is, upon the whole, better to give the nipple rest where the process of 
suckling is very painful, and indeed in any case, where the breast- 
pump works satisfactorily, and removes the accumulated secretion 
without pain, the child should be nursed by the sound breast from the 
beginning. 

The decision of weaning should not be too hastily arrived at, as the 
case may, under judicious treatment, resolve, and the infant should 
not be deprived of its natural nourishment, but in this matter the 
judgment of the physician is of great importance, and, unfortunately, 
it is not a very rare event to witness an infant tugging at a breast, the 
seat of extensive suppuration, from the nipple of which pus may be 
sucked, with pain to the mother and injury to the child. 

At the beginning of the mastitis, if coming under the physician's 
notice at this stage, the question of cold or hot applications has to be 
decided. As a rule, it may be said that cold applications are not well 
borne, and do not give satisfactory results, and their use should not be 
persisted in if a speedy diminution of the pain, heat, redness, and 
swelling does not occur. The best cold application is the ice-bag. Its 
use is often persisted in under the misapprehension that warm applica- 
tions tend to determine suppuration, but, as already mentioned under 
lymphadenitis and elsewhere, it has been pointed out that warm or hot 
applications, by relaxing the tissues and diminishing the pressure, often 
relieve the tension, which is more or less fatal to the life or integrity 
of the part affected. 

If, then, the ice-bag or cold evaporating lotions are not soon followed 
by relief of pain and diminution of the tension of the breast, they should 
be discarded for moist and warm or moderately hot applications. Of 
all the forms of applying moist warmth to an inflamed breast, the 
writer finds none so convenient and satisfactory as the following : 

A shallow wooden bowl or basin, after the fashion of a small butter- 
dish, large enough to more than cover the swollen gland, is to be pro- 
cured. After stuping the breast with hot flannel cloths, a piece of 
cotton wool or soft flannel squeezed out of hot water is to be laid in 
the inside of the wooden basin, which is then inverted upon the breast. 
If the basin is of the proper size a most soothing and comfortable" moist 
warmth can be maintained for hours. Several layers of lint soaked in 
warm spirit lotion (1 : 2) may be used instead, and covered in by a 
piece of oiled silk, in these ways all the advantages of a poultice with- 
out many of its drawbacks may be obtained. 

A favorite application is belladonna, and occasionally the physician 
may be rewarded by hearing that it gives some relief. The stereotyped 
formula of the green extract rubbed into a thin paste or cream with 
glycerin is the one generally employed. It is, however, inconvenient 
and filthy, and very often fails. Where the therapeutic action of bel- 
ladonna is desired a little of the liniment (which is almost colorless) 
may be added to the warm spirit lotion, care being taken that the 
child, if put to the breast, does not get any of it. 



484 MAMMAKY GLAND, INFLAMMATION OF. 

The following formula may be used with advantage in many cases 
where the skin is unbroken : 

li . — Lin. belladonnae . . . . . . 5 iv. 

Tinct. aconiti ^ij. 

Spt. vini rect ^ iv. 

Aquse rosee . . . . . .ad ^xij. — M. 

S. — The lotion to be applied to the inflamed breast upon lint, and covered 
with oiled silk. 

Such a warm moist application need not be changed oftener than 
every eight hours if a large thick pad of warm cotton wool be laid on 
over the oiled silk, and retained in position with a light broad bandage 
passed over the opposite shoulder. The extract with glycerin smeared 
over the surface of a warm poultice often affords relief. It is a good 
rule not to use any belladonna preparation to a breast to which the 
child is to be afterward placed. 

Arnica, sal ammoniac, jaborandi, digitalis, chloral, laudanum, stra- 
monium, hemlock, marshmallow, tobacco, hyoscyamus, and many other 
substances have been used ; but, as a rule, moist warmth accomplishes 
everything, and much more than these. Where a poultice is used the 
writer has found great satisfaction in smearing over its surface with the 
ointment of conium. This often gives better results than belladonna. 

While local measures are being used much may be done to allay the 
constitutional disturbance with minute doses of aconite or tartar emetic, 
combined with a diuretic ; but the chief indication is to check for a 
time the abundant supply of milk. This is best accomplished by a 
diet in which there is as little liquid element as is compatible with the 
patient's comfort, and at the same time the bowels should be frequently 
purged by the administration of small doses of saline cathartics, the 
best of which for this purpose is teaspoonful doses of sulphate of mag- 
nesia, or tablespoonful doses of Rochelle salts dissolved in lemonade. 

At this stage nurses are very fond of friction or massage upon their 
own account, and every physician can recall cases where mammary 
abscess has been the direct result of unwise manipulation of the gland. 
Nevertheless, friction judicially and skilfully applied will be found to 
be a powerful remedy for good, especially in those cases where the 
breast-pump or infant causes much pain to the fissured or ulcerated 
nipple. Friction when roughly applied is very liable to determine 
suppuration, and, consequently, the physician should at first carry out 
its application himself. It should be gentle and almost painless, and 
the pressure should be commenced at the periphery or circumference 
of the breast, and should be applied in lines converging toward the 
nipple, and a little oil or camphor liniment may be smeared over the 
skin before commencing the operation. 

In this way a very painful and engorged breast following upon, and 
directly caused by, a fissured nipple may be relieved of the tension 



MAMMARY GLAND, INFLAMMATION OF. 485 

resulting from retained secretion, and thus the dangers of suppuration 
may be avoided ; but where gentle friction, applied in lines from the 
circumference to the centre, causes severe pain without relieving the 
tension of the breast, its continuance should not be advised. The 
other measures recommended should then be resorted to again, viz., 
moist warmth, gentle pressure by a bandage, regulation of the diet, 
and free purgation. Iodide of potassium in large doses with belladonna 
internally and a little morphine will diminish the secretion. 

Recently, excellent results have been obtained without poultices or 
warm fomentations simply by the application of elastic pressure, and 
this, when it succeeds in giving relief as soon as it is applied, may be 
used as the only local treatment. Where there is much pain and ten- 
derness Home applies a 5 per cent, oleate of mercury and morphine 
solution, over which is placed a thick layer of cotton wool enveloping 
the entire breast. Upon the top of the wool an elastic woven or pure 
rubber bandage may be so applied as to exercise a comfortable elastic 
pressure, by passing it round the chest and over the opposite shoulder 
until the inflamed gland is evenly covered. One great advantage which 
this method produces over all others lies in the fact that the patient 
may freely move about without interfering with the rest of the inflamed 
organ. The child can drink at the sound breast until the inflamma- 
tory action subsides in the affected one, after which it may be able to 
take its share in the work of nursing. Galvanism has been tried, but 
the results are unsatisfactory. 

No treatment will be based upon truly scientific principles which 
omits to deal with the almost invariable cause of the mastitis — i. e., 
ulceration, abrasion, or fissure of the nipple. There is little doubt but 
various germs gain admission to the ducts in this way. 

When, notwithstanding the employment of these various remedies, 
it becomes evident that pus has formed, either upon the surface of the 
gland, in its substance, or in the areolar tissue behind it, its early 
evacuation by a free incision will be the first thing that will give re- 
lief. When, however, there is no sign of pointing, hot poultices or 
very warm fomentations may be continued until the matter shows some 
signs of the route by which it intends to reach the surface, after which, 
under the ether spray, an incision should be made at the most de- 
pendent part to insure thorough drainage, and if considered necessary, 
a small drainage-tube may be inserted under antiseptic conditions, and 
the abscess cavity may be occasionally syringed with weak carbolic, 
corrosive sublimate, or boric acid solution. In making the incision it 
is advisable to keep clear of the nipple lest it should become involved 
in the cicatrix, and by suffering retraction afford a barrier to future 
use ; and the knife should be directed in the course of the milk ducts 
— i. e., from the centre in a direction toward the circumference. Rarely 
will a counter-opening be necessary. 

In submammary abscesses the incision should be made along the 



486 MAIMAKT GLAND, INFLAMMATION OF. 

lower border of the gland, which need not be included in the wound, 
and a large drainage-tube should be inserted. 

Where more than one abscess cavity exists in the gland tissue, an 
incision, under antiseptic precautions, should be made large enough to 
admit the forefinger, which may be then used to break down the in- 
tervening dissepiments of inflamed glandular substance, or independent 
openings may be made, drainage-tubes introduced, and antiseptic dress- 
ings and pads of carbolic or iodoform gauze applied. Upon the first 
change of the dressings, which need not occur under ordinary circum- 
stances for three or four days, often remarkable progress in the healing 
process may be noticed. 

The application of moist warmth by poultices and fomentations 
should cease upon the arrival at a decision to incise, and the strictest 
antiseptic precautions should be rigorously insisted upon afterward. 
In many cases the child need not be weaned, though the constitutional 
disturbance will sometimes solve the problem by checking the milk 
supply in both breasts, but very often the persistent use of a good 
breast-pump will keep the sound breast secreting until the abscess is put 
upon the road to recovery, when suckling may be again permitted. 

Although one often sees in the case of poor women that a child 
continues to thrive who has all along been kept even at the inflamed 
or suppurating breast, nevertheless, it is advisable to reject the milk 
pumped out of the breasts until the severity of the constitutional symp- 
toms passes off. Sometimes weaning must be carried out where the 
sucking of the child at the sound nipple causes such a rush of blood 
and rapid secretion of milk in the inflamed breast as seriously retards 
or prevents resolution. 

Where sinuses remain long after the active mischief has subsided, 
they, and the cavities to which they lead, should be slit up, scraped by 
a Volkmann's spoon, and touched with a strong solution of chloride of 
zinc, and dressed antiseptically. 

When considerable hardness and induration remain, the breast may 
be strapped with mercurial plaster, or after rubbing in a weak mer- 
curial ointment or a solution of the oleate of the same metal, a bella- 
donna plaster may be worn, or the rubber bandage may be tried for a 
short time. Iodides internally, in full doses, may be given with advan- 
tage in such cases. 

The writer has seen a case where a series of chronic abscesses con- 
tinued to form for nearly a year, and though sinuses were freely slit up 
and scraped, and rapid healing resulted, other abscesses or sinuses ap- 
peared afterward, and only yielded to the slitting up and dissection of 
every tract where pus had formed. Such cases are wearisome, and can 
only be successfully treated by radical measures. The injection of 
antiseptic liquids, counter-irritation, strapping, pressure, and the ad- 
ministration of internal remedies are worse than useless, as they may 
only tend to keep up the irrritation. 

Galactoceles or milk cysts, when they form, should be freely opened 



MANIA— MASTUEBATION. 487 

with proper antiseptic precautions, a portion of the cyst wall excised, 
and the case treated upon general surgical principles. 

MANIA. 

As mentioned under Insanity, the treatment of the different forms 
of mental disease can only be carried out in special institutions pos- 
sessing the numerous requirements which are now considered necessary 
for the successful management of the insane. This remark applies to 
ordinary acute mania, but it will be necessary to briefly refer to the 
management of acute delirious mania (sometimes called brain fever), 
a serious and often fatal disease coming on with surprising suddenness, 
and requiring treatment before the necessary removal to an appropriate 
asylum can be determined upon or carried out. 

The first point in the management of such cases is to look closely to 
the feeding, and as the patient almost always refuses food, forced feed- 
ing thould be commenced without delay, and steadily insisted upon 
in spite of all obstacles every third or fourth hour during the day and 
night. 

Strong broths, beef essences, milk and eggs, and a small quantity of 
stimulant in most instances should be introduced into the stomach by 
means of the India-rubber tube. Nutrient enemata should be also 
given. At a later period cod-liver oil should be given in ounce doses 
when the stomach retains it. 

In addition to these supporting measures, sleep and quiet must be 
secured, and bromide of potassium and hyoscine are called for. Opium 
is to be avoided, unless other hypnotics fail. Chloral is the favorite 
drug, and with many specialists the treatment of this affection is summed 
up in the words " feeding and chloral." See under Insomnia, where 
the relative merits of all the hypnotic and narcotic drugs are fully dis- 
cussed. 

MASTOID CELLS, Suppuration of— See Bar, Diseases of. 
MASTURBATION. 

The evils arising from this filthy habit have been generally exag- 
gerated, and as regards treatment, the physician will be much more 
frequently consulted by hypochondriacs who imagine that they have 
been injured by the practice than by those who continue to pollute 
themselves by it. With children the case is different. Detected by 
their parents or guardians, the advice of the physician is often sought 
as to the best method of putting an end to the habit, and if there be 
any causes such as adherent prepuce or phymosis, or a very long fore- 
skin, circumcision generally affects a speedy and permanent cure. 

In the case of lads about puberty, who have discovered or who have 
been taught the evil habit by others, circumcision may also be resorted 
to, as an elongated prepuce is a constant source of suggestive irritation, 



488 MASTURBATION. 

and, when present, appears to greatly aggravate the vice. Moreover, 
the operation certainly makes a distinct break in the habit, which with 
close supervision and good moral treatment, may end in a complete 
emancipation from the thraldom which some boys have not the force 
of character to break through without external assistance. 

In the case of girls, any unhealthy condition of the genital organs 
may lead to the establishment of the habit, and absolute cleanliness, 
with close supervision, may lead to a removal of the trouble. With 
older girls, who have been educated by others into the practice, only 
moral treatment will be of use. These cases are most unsatisfactory, 
as too often masturbation gets hold of those in whom the moral sense 
is not very acutely developed, and there may be little to appeal to. 

It is often a symptom of mental deficiency or the first indication of 
some psychological disturbance, and has too often been regarded even 
by specialists as the cause instead of the result of insanity. 

Where moral treatment fails, resort to mechanical methods of pre- 
venting the act may be tried by tying the hands after undressing at 
bed-time, and by arranging that the patient shall not sleep alone, or 
by causing the patient to sleep with a hard body like an empty cotton 
reel fastened over the spine, so that when he turns upon his back during 
sleep its pressure awakes him. The plan of blistering the penis or 
labia is a severe and almost brutal method, open to serious objection, 
and not even likely to be followed by any permanent benefit. 

Free purgation, or measures to insure the regular emptying of the 
rectum and the removal of thread-worms or anal irritation from what- 
ever cause, are not to be overlooked. 

The avoidance of bad companions and indulgence in filthy conver- 
sation and impure literature must not be omitted. Free open-air exer- 
cise, pushed to the extent of inducing fatigue before bed-time, plain, 
unstimulating food, change of scene, amusements, and of surroundings, 
and attention to every measure calculated to improve the physical tone, 
should be advised. 

Where moral treatment fails entirely, drugs are not to be depended 
upon, but where there is a continual struggle between an unhealty, pre- 
cocious, sexual appetite and a weakened will, victory may be won for 
the latter occasionally by the administration of bromide of sodium or 
potassium, in conjunction with iodide of potassium and cold baths. 

Blistering over the occiput and upper cervical spines is occasionally 
useful in allaying the excitability of the sexual centres. 

The physician is often consulted by perfectly healthy patients who 
have practised the habit of masturbation for a time during boyhood, and 
who become almost distracted, after the perusal of some sample of per- 
nicious quack literature, with the thought that they have ruined them- 
selves. In such cases, the firm assurance of the physician that the 
habit has left no injury behind it generally restores the patient's mind 
to a healty state. (See under Impotence, Spermatorrhoea, etc.) 

Regarding preventive treatment, it is a serious question whether 



MEASLES. 489 

boys should be warned against the evils of a practice of which they 
may know nothing, and there cannot be a doubt but that in some few 
cases such warning may produce the opposite effect, though many 
authorities who have had considerable experience of the training of 
boys follow the practice of sounding an alarm as a matter of routine. 
To be free from objections, such warning must be most judiciously ad- 
ministered to innocent and sensitive youths. 

MEASLES. 

The treatment of all the exanthemata differs little except in points 
of detail, and the following remarks will apply also to the general 
management of scarlatina, typhus, typhoid, and smallpox. At the 
onset of the disease, the patient should be put to bed. A wire spring 
mattress, upon the top of which a thin, hard hair mattress is placed, 
and moderate amount of bed-clothes, should be provided. The tem- 
perature of the sick room should not be allowed to exceed 60°F. 

Certainly, in the absense of special reasons, such as laryngeal com- 
plications, the atmospheric temperature should not exceed 65°F. The 
most thorough ventilation should be secured, and a continuous supply 
of pure warm air is essential. Tait's thermic ventilator is the most 
valuable sick room luxury. Where the physician has the choice of 
rooms for the treatment of any of the exanthemata, he should select a 
large, airy apartment, with an open grate, and, when possible, with a 
ventilator opening into a flue. The bed can be surrounded by a couple 
of screens in a large room ; this will enable the most thorough venti- 
lation to be carried out without subjecting the patient to draughts of 
cold air. 

In the case of measles, it is customary to have the light subdued by 
partially drawing the blinds, but the complete darkness so often insis- 
ted upon is unnecessary, and the patient's own feelings may be taken 
as a guide in this matter. The less unnecessary furniture and hangings 
or drapery the better. 

In the management of scarlatina and smallpox this is of considerable 
importance, and it is well to clear everything out of the room that 
cannot be afterwards subjected to thorough fumigation or disinfection. 
The physician should give such instuctions regarding the use of disin- 
fectants during the illness as will prevent the risk of injury to the 
patient by their being employed too freely. 

In treating infectious diseases in the patient's home, it is a good plan 
to place a large vessel filled with water and Condy's fluid (about 1 : 50) 
outside the door of the sickroom. Into this vessel all articles leaving 
the room may be dipped. In the case of scarlatina and smallpox, a 
sheet dipped occasionally in a solution of carbolic acid (1 : 100) or 
chlorinated lime (1 : 200) may be suspended outside the door, in order 
to more effectually cut off the room from the other parts of the house. 
Urine and feces should be passed into vessels containing a small quan- 

32 



490 MEASLES. 

tity of some disinfecting or deodorising substance. Terebene, eucalyp- 
tus, carbolic acid, or other spray may be diffused through the atmos- 
phere occasionally. 

In the early stages of the fever of measles little drugs are required. 
The following old-fashioned mixture can do no harm, and often affords 
some relief by encouraging the action of the skin; it may be admin- 
istered until the decline of the eruption : 

I£. — Spt. rether. nitrosi . . . . . . 31J. 

Liq. ammon. acetat. 5§ij. 

Tinct. croci ........ ^j. 

Syr. et aquse ad ^ iv. — M. 

S. — A teaspoonful of this may be given every two or three hours to a child 
from two to four years of age. 

Diet must be closely attended to. Where the patient can take milk 
freely there is no difficulty, as milk alone or diluted with half its 
amount of lime-water, or aerated soda, or kali water may be given in 
any quantity. Where the patient has a natural dislike to milk, weak 
soups, beef tea, or any liquid nourishmint may be given. It is, how- 
ever, a mistake to force nourishment under these circumstances. Often 
a child who refuses milk can be tempted to take tea, and this may 
consist chiefly of milk flavored with a little tea. In such a liquid, 
biscuit may be soaked, or toast and crumb of bread may be added. 

As the fever increases diluent drinks may be freely given, and it is 
wrong to refuse cold water when the patient craves for it. It is difficult 
to see the origin of the popular prejudice against water being allowed 
to patients parched with fever. It should only be temporarily with- 
held in those instances where it is taking the place of nourishment. 
Weak barley water, to which lemon juice and a little sugar has been 
added, or homemade lemonade may be freely given. When thirst is 
very great, ice may be freely administered in small quantities. 

Coryza may be safely let alone. It rapidly subsides upon the decline 
of the eruption, and is generally relieved by cutting off the supply of 
bright light. 

Cough is often most troublesome, and in some cases almost alarming 
and is liable to resist drugs until the eruption begins to fade. The 
diffusion of steam through the air or an inhalation of conium or very 
weak carbolic spray to the fauces, with ipecacuanha wine internally 
and warm poultices externally generally afford relief. In adult patients 
tartar emetic (20 minims of the wine, with y 1 ^ to -fa grain of morphine) 
may be given with advantage. 

Fever when running very high must be checked, and, as there is 
a strong objection to the cold bath as an antipyretic before the appear- 
ance of the eruption, the temperature should be watched, and when it 
reaches above 104° an antipyretic should be administered. 

Antipyrine or antifebrin may be safely given in measles under such 



MEASLES. 491 

circumstances, though their routine administration in all cases of the 
disease is unnecessary. Two grains of antipyrine or \ grain of auti- 
febrin may be given every three hours to a child from one to two years 
old. When hyperpyrexia occurs after the rash has come well out, and 
where the temperature reaches 106° or more, a cold bath or cold pack 
should be at once given, and the patient kept in it until the tempera- 
ture falls to normal. Waugh thinks that the disease may be cut short 
by phenacetin. The bowels should recieve one moderately smart 
clearing out by a saline purgative, and further purgation is unnecessary, 
unless constipation set in. Diarrhoea, if present, should not be inter- 
fered with, unless it threatens to exhaust the patient's strength. 

Itching, when the eruption is well out, may be a troublesome symp- 
tom. It is generally relieved by sponging the limbs and face with a 
warm or tepid solution of bicarbonate of soda. 

Where convulsions occur, or where stupor with marked exhaustion 
is observed before the appearance of the eruption over the entire body, 
especially when traces of it have been observable for one or two days 
about the head, a hot bath should be given, with the view of causing a 
smart determination of blood to the cutaneous surface. After such a 
bath the body should be properly rubbed dry with warm towels, and 
the patient wrapped up in flannels and put to bed before the possibility 
of a chill occurs. 

Convulsions at a later stage generally indicate the onset of some 
serious complication, such as pneumonia or meningitis, which is to be 
met by the administration of such remedies as are indicated in these 
affections. Pneumonia is apt to run a very protracted course, and 
must be met by ammonia, quinine, stimulants, and hot poulticing. 

Bronchitis, catarrh of the meatus or troubles in the middle or inter- 
nal ear, ophthalmia, adenitis, and other complications, are to be met by 
the remedies mentioned under the names of these affections. 

Stimulants are seldom necessary in ordinary uncomplicated cases ; 
but where serious complications as those just mentioned are present 
they must be judiciously administered. The exhaustion and serious 
drain made upon the system by severe attacks of measles often lead to 
a fatal issue, notwithstanding the popular notion that the disease is 
generally a trivial ailment. 

Hence, after the decline of the eruption, every care must be taken to 
keep up the general strength by large quantities of easily-digested and 
easily-assimilated food. The after-treatment is sometimes of much 
greater importance than the management of the case prior to the decline 
of the fever. Tonics may be needed to improve the appetite, and iron 
to combat the anaemia which often results. These objects may be ac- 
complished at the same time by giving a mixture containing quinine, 
with small doses of the tincture of iron. Cod-liver oil is very valuable 
at a later stage. Where convalescence is protracted, stimulants may 
be employed in the after-treatment with advantage, and when admin- 
istered they should be given with the food. Thus brandy or whiskey 



492 MEGRIM, MIGRAINE, OR HEMICR ANI A . 

may be added to the milk. The writer prefers to give the stimulant in 
the form of wine whey, which can be readily prepared by adding one 
wineglassful of sherry to one pint of milk, raised almost to the boiling- 
point ; the fine curd should be rejected. Children, as a rule, take this 
mixture readily. When whooping-cough is present, a not uncommon 
complication, the case calls for very careful management, free stimula- 
tion being sometimes essential, and further pulmonary troubles must be 
met by smart counter-irritation and stimulating expectorants. 

Bichloride and iodide of mercury have been used internally as 
routine remedies, but the writer has no experience of their use. The 
solution of peroxide of hydrogen has given good results. 

In the absence of complications, the patient may generally be per- 
mitted to leave his bed, though still to remain in his room, after the 
lapse of a week. It is difficult to keep those who have just passed 
through a mild attack of measles from exposing themselves to the vari- 
ations of temperature out-doors. The children of the poorer class run 
about often before the eruption has entirely faded, and the result is that 
large numbers of them perish from secondary bronchial or pneumonic 
troubles. The dangers of exposure should be insisted upon to parents, 
and the body should be well enveloped in flannels, even in the summer 
time. In winter, a child should not be permitted to take open-air exer- 
cise for at least a month after the seizure. Drives should not be per- 
mitted until the patient has been allowed to move about. To all who 
have had much experience in the extern department of a children's 
hospital, it is evident how numerous are the cases of phthitis and severe 
visceral and bone affections, whose origin can be traced to the shattered 
state of health following severe attacks of measles. In the writer's 
experience, which is not limited in this manner, such serious sequeke 
are much more common after measles than any other affection, and 
they point to the necessity for prolonged careful feeding and nursing, 
long after the period when danger is generally supposed to have passed 
over. 

MEGRIM, MIGRAINE, OR HEMICRANIA. 

The treatment resolves itself into the management of the attacks, 
and also into the employment of such measures as will tend to prevent 
their recurrence. 

Of all the agents ever used to relieve the pain of megrim, none can 
be compared in certainty or rapidity of action to antipyrine or antife- 
brin. The action of these remedies still requires satisfactory explana- 
tion. Though there is no doubting there marvellous efficacy, neverthe- 
less, it is difficult to explain their modus operandi. Patients, who for 
years have been periodically laid aside, unable for shorter or longer 
periods to discharge the duties or enjoy the pleasures of life, notwith- 
standing the use of the older narcotics, have been now placed in the 
position, thanks to antipyrine, that they need not suffer many minutes' 
pain or inconvenience. For the past three or four years since the 



MEGRIM, MIGRAINE, OR II EMIGRANT A. 493 

writer first used this remedy for the pain of megrim, he has not seen 
one case where it failed to give marked relief. 

As soon as the patient feels the first symptoms of an approaching 
attack, he. should be directed to take 10 grains of antipyrine, or 5 or 6 
grains of antifebrin in the form of a powder, mixture, or tabloid. 
Should the pain continue, half these quantities may be given every 
hour for three or four times, but it is rare for an attack to stand out 
against the second or third dose. Where there is any reason to suspect 
that the drug may disagree or produce unpleasant symptoms, half the 
above doses may be given every thirty minutes. There is evidence 
that patients suffering from high fever can take much larger doses of 
antipyrine than if the temperature was normal. And, though the 
writer only once saw any unpleasant effects from the drug in some 
thousands of administrations in numerous diseases, many instances of 
untoward results have been published from time to time, and it may 
be, upon the whole, wiser to give smaller doses, say, 3 or 4 grains every 
twenty or thirty minutes, until relief follows. Bokenham reports the 
treatment of twenty-six cases ; in every case the result was perfectly 
satisfactory, though the dose never exceeded 4 grains, and generally 
only two doses were necessary. An augmentation of the original dose 
is seldom required in after-attacks. 

Exalgine will probably be found to give equally satisfactory results. 
The experiences of antipyrine, apparently for so far, meet every require- 
ment, and it may be considered unnecessary to enumerate the various 
drugs which have been hitherto employed to relieve the attack. But, 
as antipyrine sometimes fails to cut short attacks which cannot be 
regarded as those of typical megrim, and as other agents are decidedly 
beneficial in such cases of what may be called " migrainous headaches," 
the most important of them may be here enumerated. 

Little, up to October, 1885, stated that he did not know of any 
treatment which had any distinct power of cutting short an attack of 
migrainous headache when it came, or even of mitigating its severity, 
discovered that 20 grains of salicylate of soda generally gave speedy 
relief. He recommends it to be taken in a wineglassful of water, to 
which a dessertspoonful of the effervescent granular citrate of caffeine 
has been added. The dose administered in this form is not unpal- 
atable, and it may be repeated in two hours again, if necessary ; and 
he found that it did not lose its power in relieving subsequent attacks. 
The writer is not aware that this remedy has been found to relieve 
migrainous headache where antipyrine has failed, but its use is clearly 
indicated when such cases are found to occur. In some of the writer's 
cases the antipyrine seemed to lengthen the intervals between the 
attacks. 

Haig has closely studied the relations existing between the parox- 
ysms of megrim and the excretion of large amounts of uric acid, and 
found that by the administration of full doses of any acid he could at 
pleasure check the amount of uric acid in the blood and in the urine. 



494: MEGRIM, MIGRAINE, OR HEMICR ANI A. 

He gave 60 minims of diluted nitro-hydrochloric acid in a tumblerful 
of water, one-half of which was swallowed as soon as the pain came 
on, and the other half in thirty minutes later ; the headache was gen- 
erally removed in about an hour after the second dose. An equivalent 
of citric acid does equally well. The writer has not been able to 
corroborate this observation in a few cases in which he has tried the 
acid treatment. 

Indian hemp is a drug which has been found of considerable value 
in megrim, and the reports of Anstie, Seguin, Greene, and others, show 
that it not only relieves, but that it has been found to decidedly cure 
the disease, as the bromides sometimes do in epilepsy, J grain of the 
alcoholic extract being given night and morning for eight or twelve 
weeks. One statement made by Greene is at variance with the writer's 
experience. He states " that, unlike opium, no craving for further 
doses follows its medicinal use, and apparently it can be given up 
without the slightest effort at any time." In severe cases it can be 
given with advantage after antipyrine has been employed to relieve 
the pain. It is also a remedy of great value in continuous headache, 
especially when occurring in women. 

Bromide of potassium or sodium is sometimes of use in 30 grain 
doses in relieving the paroxysms, but it far more frequently fails, and 
in the typical form of the disease it appears to have no appreciable 
effect in preventing the attacks, and since the virtues of antipyrine 
have been demonstrated, it will gradually fall into disuse, except in the 
irregular or aberrant types of migrainous headaches. 

This drug may in some cases be advantageously combined with anti- 
pyrine. Thus — 

Be. — Plienazoni 3J SS - 

Potassii bromidi 3 iv. 

Spt. chloroforini . . . . . . ^ ij. 

Aquae camphorse ad ^viij. — M. 

S. — A large tablespoonful for a dose, when the attack of headache comes on, 
and a dessertspoonful every morning and evening between the attacks. 

Caffeine and strong coffee occasionally give some relief, and may still 
be employed in conjunction with antipyrine and cannabis. 

Guarana, or an extract prepared from the ground seeds of paullinia 
sorbilis, which contain the alkaloid guaranine, is more efficacious than 
caffeine, with which it is identical. Five grains of the alkaloid, or 25 
or 30 grains of the cake, may be given every two or three hours. It 
was, perhaps, the best routine treatment prior to the introduction of 
antipyrine treatment, but it very frequently failed entirely. 

Chloral hydrate, by inducing sleep, may sometimes be found to cut 
short the attack. 

Croton-chloral or butyl-chloral hydrate is of feeble power in megrim, 
and in the absence of neuralgia of the fifth nerve is not worth a 
trial. 



OR HEMICRANIA. 495 

Nitrite of amyl or nitro-glycerin may be tried in migrainous head- 
ache, but in the typical form it only occasionally gives any relief. 

Menthol, cajuput, and eucalyptus oils have been given in doses of 
5 to 10 grains or minims with very variable degrees of success. 

Cysticine, the active principle of the laburnum, and found also in 
arnica, has been reported as very efficient in the treatment of violent 
cases associated with dilatation of the vessels. The hypodemic in- 
jection of 0.003 gramme may be given upon the strength of Krsepelin's 
statement. It is a remedy of which the writer has no experience, and 
since the introduction of antipyrine may never be again employed. 

Morphine hypodermically has been recommended, but the remark 
just made will apply also to it; and tonga, belladonna, picrate of 
ammonia, ergot, gelsemium, actsea, picrotoxin, digitalis, camphor, am- 
monium chloride, alcohol in one full dose, henbane, valerian, sumbul, 
and many other drugs vaunted as cures from time to time, may be 
dismissed with the same remark. 

Locally, some agents may be useful at times in conjunction with 
the treatment already detailed. Among these may be mentioned 
warmth to the head, the ice bag, ether spray or methylene spray, 
sinapisms to the back of the neck, tight bandaging of the head, and 
exclusion of light, atropine to the eyes, belladonna to the forehead, and 
menthol or veratrine in the form of ointment over the brows. 

Galvanism is of undoubted value, especially in the continuous 
migrainous headaches, and the writer has found it of much benefit to 
those who suffer from more or less constant headache between the 
attacks of megrim. The current from four or five Leclanche elements 
may be passed through the head for two or three minutes at a time, one 
pole resting upon the forehead, and the other below the occiput. 

Purgatives are generally useless, and the darkened room is not indi- 
cated when we have drugs capable of giving speedy and complete 
relief. 

Of the treatment between the attacks little can be said until their 
cause has been discovered, and in some instances a brilliant effect may 
be produced by correcting the fault to which they owe their origin. 
Thus, if the megrim has been depending upon some errors of accom- 
modation or upon astagmatism, the paroxysms may never return after 
these have been corrected by suitable glasses. Severe mental work, as 
a rule, does not produce megrim, but mental worry is a very common 
cause. Vexations of one kind or another, and irregularity in the 
hours of sleep, and prolonged anxiety or grief, are common factors. 
When such can be avoided, as by change of scene and occupation 
marked relief follows. 

Though much has been written about the effect of tonics, the virtues 
of strychnine, bromides, iron, cod-liver oil, purgatives, special dieting, 
etc., little dependence need be placed in any of them, only in as far as 
they bring a debilitated organism up to a healthy standard, after which 
constant open-air exercise at every available opportunity, regularity in 



496 'MelJena. 

the hours of meals, time of rest, and in the periods of intellectual labor, 
will do much to prevent return. Constipation, insomnia, indigestion, 
lithsemia, etc., must be relieved, and, in the case of children, the short- 
ening of school hours and the abolition of the pernicious cramming 
plans, the indirect outcome of the objectionable " result fees " system, 
may achieve a good deal. 

Of the various specific drugs which have been found beneficial in 
the prevention of megrim, there is much difference of opinion about 
their relative values. The writer finds a long course of arsenic in 
small doses as the best, To this may be added a pill of the extract of 
Indian hemp, as already mentioned ; 3 grain may he given at bed- 
time. Chloride of ammonium, iodide of potassium, phosphorus, and 
salicylates, with alkalies, may be tried where arsenic fails. No harm 
can result from a nightly dose of the bromide of sodium or potassium 
in conjunction with as much cascara sagrada as will keep the bowels 
open without purging. 

Little advises sponging with hot water in the morning, followed by 
a cold douche over the shoulders and spine, and a sparing use of tea, 
with the following pill to be taken after breakfast and dinner : 

R . — Sodii arsen. ........ gr. y^. 

Ext. cannab. md. . . .... gr. ^. 

Ext, belladon. ... . . _ . . gr. ■§-. 

Zinci valerian. ... ... gr. ij — M. 

Make twenty-four of such pills. 

MELiENA. 

As this symptom depends upon the outpouring of blood into the 
stomach, small intestines, or the upper part of the large intestine, its 
treatment will depend upon the cause of the hemorrhage. Thus an 
ulcer of the stomach, congestion of the liver, or ulcers in the duodenum 
or intestinal tube high up, may be the origin of the blackened or tar- 
like evacuations, and the appropriate treatment will consist in the judi- 
cious administration of remedies calculated to check the original dis- 
ease. Under Hsematemesis will be found the remedial agents used to 
stop the bleeding when its seat is in the stomach. 

Most of these drugs are administered when the bleeding is from a 
point lower down in the alimentary canal. Acetate of lead and opium, 
alum in large doses, and the extract of hsematoxylon in pilular form, 
and turpentine in the form of capsule, are employed to reach the 
bleeding surface in the small intestine. 

MELANCHOLIA— See Insanity and Insomnia. 
MENIERE'S DISEASE— See page 222, and see under Tinnitus, 



M E N I N G I T IS, CERE B K A L (S I M P L E ) . 497 

MENINGITIS, Cerebral (Simple). 

The treatment of the original condition is of importance when the 
meningeal inflammation is found to be secondary to erysipelas, or dis- 
ease of the petrous portion of the temporal bone, or when it occurs in 
the exanthemata, in pneumonia, syphilis, ulcerative endocarditis, and 
injuries to the cranial bones. 

The patient should be put to bed and kept upon his back, with his 
head elevated. The utmost mental quiet and absence of noise, bright 
light, and jarring vibrations of every sort, must be ensured. 

Diet should consist of small quantities of iced milk ; and in the 
earlier stages animal food, even in the form of beef tea or meat ex- 
tracts, should not be administered, and the same remark applies to 
alcoholic stimulants. One smart purge should be given to ensure the 
thorough evacuation of the intestinal contents. A moderate dose of 
calomel, followed in five or six hours by a saline cathartic, is a good 
routine method of accomplishing this object. 

Where pain is a very prominent symptom, two or three leeches may 
be applied to each temple or behind the ears. 

Cold to the scalp is the most valuable local treatment, and in order 
to ensure its application to the best advantage the hair should be cut 
close by sharp scissors, or, better still, the head should be thoroughly 
shaved. A light rubber ice-cap or bag, or a bladder moderately filled 
by small pieces of ice, should be applied evenly to the forehead and 
scalp. Where this is not at hand, a good substitute may be quickly 
extemporized by tying up a quantity of broken ice in a sheet of thin 
gutta-percha tissue and applying it in the same way. Cold lotions, or 
compresses of lint or linen containing small pieces of ice in their folds, 
may also be used. Leiter's tubes are sometimes preferred. A hand- 
kerchief wrung out of iced water, and frequently renewed, answers 
well in the case of restless children. The persistent use of cold 
applications to the head always affords some relief, and may induce 
sleep after other methods fail. 

Counter-irritation to the nape of the neck and occiput is a valuable 
agent in relieving pain and restleness, but this should seldom take the 
form of blistering, especially as the patient lies upon his back, and a 
large blistered surface in contact with his pillow and supporting the 
weight and pressure of his head and neck is liable to be followed by 
very unpleasant results. Mustard poultices fulfill every requirement, 
and they can be repeatedly applied if thought necessary during the 
illness. 

Blisters to the scalp are used by some physicians. Their utility is 
very doubtful. They should not be tried except where for some cause 
the ice-bag or cold applications cannot be used, and, moreover, they 
produce great discomfort in the early stages of the affection. 

Where these measures fail to relieve headache and induce sleep, the 



498 MENINGITIS, CEEEBEAL (SIMPLE). 

important question of administering opium crops up. About this there 
have been very varying opinions held, but it may be said that those 
who have most experience express the least hesitation in giving it. 
Since the discovery of Lepine of the analgesic properties possessed by 
the new hypnotics, there is not the same difficulty about relieving 
headache ; and the writer has employed antipyrine with much satis- 
faction in small and frequently repeated doses in meningitis. He has 
not had an opportunity of giving exalgine in such cases, but it may 
be found better than either antipyrine or antifebrin. Sulphonal or 
chloral may be given to induce sleep when the pain is relieved by 
other measures. 

Bromide of potassium is sometimes of use in allaying cerebral ex- 
citement, blunting pain, and inducing sleep, but as a rule only disap- 
pointment is to be expected from it in severe cases. It may, however, 
be freely given when convulsive seizures are a prominent feature in the 
case. It can be also given to great advantage under these circum- 
stances in combination with antipyrine. (See the formula upon page 
494.) 

Iodide of potassium in large doses may be tried with some hope of 
success where vomiting and gastric derangement are absent, and in 
the later stages of syphilitic meningitis it may be very valuable. 

Vomiting may be best relieved by giving small pieces of ice to be 
swallowed whole, and by administering a plain effervescing mixture 
containing a few minims of liquor morphince (1 : 100) with hydro- 
cyanic acid and bismuth. 

Aconite alone, or combined with bromides, is of value where there 
is much fever and rapidity of pulse, with a dry skin. 

Cold douches and cold affusion have been successful, especially in 
cases following exposure to the sun or strong heat. 

Where the headache, delirium, fever, and insomnia appear to be 
uninfluenced or aggravated by these measures, and the disease appears 
to be rapidly passing into the stage of exudation, the advisability of 
blood-letting should be considered. Cases are upon record where this 
remedy appears to have been the means of cutting short the attack 
and saving life ; and since the duration of the disease is often so short, 
the extraction of blood is not likely to be followed by an asthenic 
condition dangerous to the patient's ultimate recovery, as is the case 
in affections running a chronic course. 

The writer's experience of blood-letting for meningeal inflammation 
is unfortunately confined to one fatal case, but he would not hesitate 
to employ it again in a suitable case after the ordinary remedial agents 
had failed. 

When exudation has already taken place, as evidenced by stupor 
and approaching coma, with alteration of pulse and pupils, some 
recommend blood- letting even at this stage, but there are good reasons 
for believing that when coma has set in the indications for venesection 
have passed away. When the patient is still able to swallow, iodides 



MENINGITIS, CEREBRAL (SIMPLE). 499 

may be pushed in large doses if not already administered, but should 
they have been given from the first, there is little hope to be gained 
from a further trial. 

Purging may now have a chance, and a saline cathartic may be 
given, so as to produce frequent watery evacuations every two or three 
hours, and there have been rare examples of the benefits of this 
measure even when stupor bordering upon coma had supervened. 
Croton oil may be given when swallowing is impossible or difficult. 
Any benefits to be obtained from this treatment may be expected to 
show themselves very soon, and it is obvious that it cannot be long con- 
tinued. 

Supposing the case to have gone on from bad to worse, and coma to 
be now established, is the physician to surrender his arms and retire 
from the contest? or is he to content himself with ice to the head or 
blistering of the scalp? Doubtless by leaving all cases to nature the 
physician may once or twice in a life-time see a recovery. 

When one studies the reports of the active treatment of the last 
generation of practitioners, two conclusions may be safely arrived at : 
1. That some lives have probably been sacrificed to injudicious and 
indiscriminate leeching, blistering, purging, and blood-letting, especially 
when commenced at an early stage before a correct diagnosis was pos- 
sible; 2. that at a later stage, in apparently desperate or hopeless 
cases, a larger proportion of recoveries may be noted after such treat- 
ment than occurs where simple expectant measures are employed. 

The writer has witnessed such unmistakeable benefits follow the free 
use of mercury, that he is driven to the conclusion that to withhold 
this remedy in desperate or apparently hopeless cases of simple menin- 
gitis is unjustifiable. He is aware that this is strong language, and 
that by taking such a position he lays himself open to the censure of 
those who refuse to believe in the efficacy of drugs where the modus 
operandi of their action is not open to demonstration. 

Nothing is easier than to cry "post hoc non propter hoe" when 
recovery follows salivation, but he who witnesses the rapid recovery 
of consciousness after the inunction of mercury, in a patient who has 
remained in a state of coma, with insensible pupils, local paralysis, 
squint, etc., will be slow to attribute the recovery to nature, since 
without the employment of the drug he never has witnessed the same 
astonishing phenomenon when the case has been treated with other 
drugs. 

Given, then, a case of simple meningeal inflammation, in such a 
stage as that just referred to, there should be no hesitation in rubbing 
in the ungt. hydrargyri for thirty minutes into the skin on the front of 
the abdomen, groins, and arm-pits. Where no evidences of improve- 
ment or of salivation are forthcoming, the inunction may be repeated 
in twelve hours again. 

It is no objection of a serious nature to urge against this plan of 
treatment that there is a possibility or probability of the presence 



500 MENINGITIS, CEREBRO-SPINAL. 

of tubercle. Such an event may not be capable of demonstration, and 
if tubercle exists, the case is one which, in the present state of our 
knowledge, we are in the habit of regarding as one which is certain to 
end in a fatal issue. 

The writer has satisfied himself that he has seen at least one patient 
who was snatched from death by this treatment, after coma and 
paralysis had lasted nearly a week, and he has repeatedly witnessed 
surprising amelioration of the symptoms and return of consciousness 
even in cases undoubtedly of tubercular nature. In the case just 
referred to there could not have been any syphilis, and the patient is 
still living and perfectly healthy since the attack — fifteen years ago. 
In meningitis from fracture of the bones at the base of the skull, 
Hutchinson strongly insists upon the benefits of early salivation, which 
he says is harmless. (See also page 333.) 

When the acute symptoms have passed away, the greatest care will 
be required in dieting, a return to animal food or stimulants being 
likely to be followed by a return of the headache. For a long time 
absolute rest and freedom from all excitement must be insisted upon, 
and tonics or iron should not be resorted to until the patient is able to 
move about. Bromides and iodides combined afford the best treatment 
at this unfortunately rare stage of the malady. Rectal feeding may 
be necessary during the prolonged coma, when swallowing is im- 
possible. 

Chronic cerebral meningitis, being secondary to other affections, its 
treatment will consist in the remedies applicable to the primary lesion. 

MENINGITIS, Cerebro-Spinal. 

The epidemic forms of this affection, also known as cerebro-spinal 
fever, are so variable in their symptoms and degrees of severity, that 
there is much difficulty in giving any outlines of treatment which will 
be applicable to the majority of cases coming under the notice of the 
physician, especially since it has been observed that agents of use in 
one outbreak have been found to be productive of mischief in others. 
No drug can be said to exert any specific action upon the disease ; but 
various remedial agents have been found to control or modify the 
symptoms and to tide the patient over the critical stages of the affec- 
tion, so as to give Nature a chance of asserting her influence. 

The patient should be placed in bed is a quiet, darkened, well-venti- 
lated room, with his head and shoulders slightly raised by pillows, and 
the general treatment applicable to cases of cerebral meningitis may 
be adopted. 

In sthenic examples of the disease blood-letting may be necessary, 
either in the form of venesection, wet cupping to the spine and occipital 
region, or leeching of the same localities, and smart purging is some- 
times useful. In asthenic cases, or when collapse ushers in the disease, 
the opposite line of action must be promptly taken by administering 
alcoholic stimulants and concentrated nourishment in free and some- 



MENINGITIS, SPINAL. 501 

times even in unlimited amounts, with warmth and sinapisms to the 
surface. 

Pain calls for analgesic remedies, and most authorities use opium or 
morphine liberally. Possibly autipyrine, autifebrin, or exalgine may 
be found preferable, especially when the temperature is high at the 
same time. Some authorities regard opium as the only remedy to be 
relied upon all through the attack, and Stille gives 1 grain every hour 
or two hours. 

Cold compresses, evaporating lotions, or the ice-bag, not only relieve 
pain in most cases, but they appear to have some beneficial action, as 
in cerebral or spinal meningitis. Occasionally cases have been met 
with where warm applications have given relief. 

High temperature may be relieved by the cold pack or by antipy- 
retics. As just stated, the" new febrifuges may be tried, though the 
writer is not aware of any reports of their use. Warm or even hot 
baths or packs may be indicated when the asthenic types of the disease 
are met with. 

Quinine has enjoyed some reputation in cerebro-spinal fever, but its 
usefulness is denied by many. It would probably act best in malarial 
forms, or where the fever was running very high, or in asthenic cases. 
To be of use large doses should be given at short intervals. 

Bromides, combined with belladonna, morphine, ergot, antimony, 
chloral, digitalis, gelsemium, and aconite, have been recommended, 
but any benefit obtained is probably owing to the action of bromides 
in this stage. 

When effusion has taken place the same measures whose utility has 
been discussed under the head of Cerebral Meningitis may be tried. 

These are (1) blistering, (2) purging, (3) iodide of potassium, (4) 
mercury. Iodide of potassium is the least objectionable of these 
methods. As the disease is so frequently characterized at this stage 
with asthenic symptoms, it must be given in full doses to be of any use, 
and 10 grains may be given every five or six hours. Where it fails in 
showing any signs of causing absorption of effused products, and where 
these are manifestly incompatible with life, owing to the pressure which 
they are exerting, there is nothing left but to bring the patient rapidly 
under the influence of mercury by rubbing in the ointment of the 
Pharmacopoeia. 

Blisters may be tried at a later stage if mercury succeeds in warding 
off the urgent symptoms, and they may be very useful in very chronic 
or prolonged cases alone, or in conjunction with the continuous current, 
massage, hydropathy, etc. 

MENINGITIS, Spinal. 

The treatment of this affection is to be carried out upon the same 
principles as are applicable to the management of cerebral meningitis, 
and need not be dwelt upon in detail. They are the same for spinal 



502 MENINGITIS, TUBERCULAR. 

pachymeningitis, arachnitis, and the varieties of spinal leptomeningitis, 
and they may be summed up under the following heads: 

1. Absolute rest in the horizontal position on the left side or face. 

2. A diet chiefly of milk and farinaceous foods, with little or no 
stimulants. 

3. Local bleeding by leeches and wet cupping on each side of the 
spine. 

4. The free use of cold, as with the spinal ice-bag or cold compresses. 

5. Where these cannot be borne, warm poultices or spongio-piline 
wrung out of warm or moderately hot water. 

6. At a later stage, the application of narrow blisters applied along 
each side of the spinal column. 

7. Free purgation by saline cathartics. 

8. The internal administration of large doses of the iodides in com- 
bination with remedies calculated to relieve pain, as hyoscyamus, mor- 
phine, antipyrine, Indian hemp, bromides with chloral. 

9. Mercury may be tried in small doses. The results of salivation 
by inunction are not so satisfactory as in cerebral cases. Ergot and 
belladonna have been tried, upon the theory that they influence the 
circulation in the smaller bloodvessels in the cord and meninges, but 
they seldom do any good. 

10. At a later stage hot baths, alternately with warm packs and hot 
douches, are of unquestionable value. The hot brine baths of Droit- 
wich may be of use in the late stages of very chronic cases. 

11. A weak galvanic constant current passed from the occiput to the 
sacrum is highly recommended by Erb. 

12. Suspension at a later stage, when all inflammatory action has 
subsided, and when iodides and small doses of mercury have failed to 
cause absorption of inflammatory products. (See under Locomotor 
Ataxia.) Massage may also be employed. 

MENINGITIS, Tubercular. 

The chief measures from which any results are to be expected in 
this almost hopeless malady are detailed under Cerebral Meningitis. 
Where the diagnosis is beyond a doubt (which it seldom, if ever, is) 
the more active agents, especially blood-letting, blistering, and severe 
purging, are clearly contra-indicated. These measures may be here 
briefly enumerated : Absolute rest in a darkened, quiet, well-ventilated 
room, with the head elevated, a diet of iced -milk frequently adminis- 
tered in small quantities, and one smart calomel purge at the begin- 
ning of the disease. Cold to the head by means of ice or evaporating 
lotions after the hair has been shaven off the scalp, counter-irritation 
by sinapisms applied to the nape of the neck. Bromides or antipyrine 
to relieve headache which has resisted the above agents, opium being 
of very doubtful utility. Chloral or sulphonal may be given to in- 
duce sleep. 



MENINGITIS, TUBERCULAR. 503 

Iodide of potassium is the routine remedy to be administered in 
ordinary typical cases of the disease. It may be given with advantage 
in combination with the bromide, but full and frequently repeated doses 
are necessary if given at all. A child two years old may get 1 grain 
of the iodide and 2 of the bromide every two hours while the stomach 
is able to retain it. 

Forced nourishment by milk should be carefully attended to through- 
out, and where milk is refused beef tea or chicken soup may be substi- 
tuted, though animal food in any form is to be objected to as long as 
mild, farinaceous foods or eggs are swallowed and digested. 

Where in spite of these measures the case goes on from bad to 
worse, and as stupor deepens into coma, and the pupils become dilated 
and sluggish or fixed, the stage mentioned under simple Cerebral 
Meningitis is arrived at and the same problem is to be considered, and 
the physician is to decide whether further interference is justifiable 
The considerations mentioned in detail upon page 500 apply for the 
most part here also. There is generally a doubt about the diagnosis 
being tubercular, and in this doubt lies the slender thread of hope of 
a successful issue. Where meningitis supervenes upon tubercular lung 
disease, or under such circumstances as leaves the diagnosis positive, 
the case may be left to its inevitable termination, but as long as any 
doubt remains, and as long as there is any reason to hope that the 
disease may be simple meningitis, the physician should rapidly bring 
the patient under the influence of mercury by inunction. Against 
this procedure little can be. said beyond that it will be useless in the 
opinion of those who do not believe in the efficacy of mercury to cause 
the absorption of effused inflammatory products, it cannot increase the 
patient's discomfort, since he is already beyond the reach of feeling, 
and it is not likely to hasten the fatal issue. Mention need hardly be 
made of the possibility of its exerting an influence in destroying the 
chance of a natural cure, since this is supposed to be abandoned in the 
imaginary case under consideration. It may be worth while to state 
that the remarkable recovery before referred to under Simple Menin- 
gitis was in a patient, the daughter of a hospital nurse. Her case 
was regarded as hopeless, as she was believed to be dying from tuber- 
cular meningitis by those who had seen her, and after profound coma 
and squint had lasted several days, the writer, with the full consent of 
the patient's mother, rubbed in a quantity of mercurial ointment more 
as a pharmacological experiment than with the hope of producing any 
marked amelioration of the symptoms. As a free and copious secre- 
tion of saliva poured out of the mouth some hours afterward, the 
patient opened her eyes after a short time and rapidly gained conscious- 
ness and made a speedy recovery. The case was almost certainly not 
of a tubercular nature, or such results could hardly have occurred. 
Since then the writer has frequently satisfied himself that even in the 
undoubtedly tubercular form of the disease, mercury has the power 



504 MENORRHAGIA. 

of rapidly causing the coma or stupor to clear off for a time before 
death. 

Recently the operation of tapping the subarachnoid space in the 
spinal cord is being advocated, with the view of draining the ven- 
tricles. 

MENORRHAGIA. 

Profuse menstruation or excessive hemorrhage from the uterus at the 
menstrual periods may be bracketed with 

Metrorrhagia, or hemorrhage occurring between the menstrual 
periods, and not necessarily arising from disordered menstruation. 

These conditions being merely the result of constitutional or local 
causes, no treatment can be of any permanent use which does not 
strike at the cause of the increased flow. Hence the proper treatment 
of menorrhagia will embrace remedies directed to such different dis- 
orders as the following : Bright's disease, pulmonary, cardiac, and liver 
affections interfering with the circulation, mental disturbances, blood 
diseases as purpura and malaria, uterine ulcerations, cancer, tumors, 
and displacements, subinvolution, ovarian congestion, climacteric dis- 
turbance, etc. After or while appropriate treatment is being directed 
to these causes of profuse menstrual discharge or metrorrhagia, certain 
routine methods of treatment may be pursued. 

Rest in the horizontal position upon a hard bed or couch, with light 
clothing and cold milk diet, with dry biscuit, is, perhaps, the most 
potent of all the host of remedial agents ordinarily employed to check 
profuse hemorrhage from the uterus. In many cases depending upon 
widely different causes, absolute rest in the horizontal position tides the 
patient over what would otherwise be a weary and exhausting period, 
which drugs could scarcely modify to any appreciable extent if the 
patient had kept moving about. 

Ergot or ergotine alone, or combined with large doses of quinine, 
stands far ahead of all drugs in the routine treatment. It may be 
given in teaspoonful doses of the fluid extract, or in the pilular fjrm, 
each pill containing 1 or 2 grains of ergotine, every six hours, or 
oftener in severe cases, or a solution of ergotine may be injected into 
the buttock or uterine walls, or 2 or 3 grains may be administered as 
a suppository or medicated pessary. 

The following combination is useful : 

H. — Ext. ergotse . gr. jss. 

Ext. cannab. ind. ........ gr. },. 

Quininse sulphatis gr. iij. — M. 

Make 24 of these pills. 
S. — Take one every four hours. 

Morphine or cannabis indica, given in doses sufficient to soothe pain 
and tranquillize the circulation without inducing narcotism, is always 
of use. 



MENORRHAGIA. 505 

Iron in ansemic and saline cathartics in plethoric cases are of un- 
doubted value. 

Bromides in full doses are clearly indicated in ovarian irritation. 

Hydrastis canadensis, in doses of 15 minims of the fluid extract, 
often succeeds even in cases where ergot has been unsatisfactory. 

Digitalis, actsea racemosa, haraamelis, chlorate of potassium, oxide of 
silver, guaiacum, rue, senega, savin, strychnine, salix nigra, creasote, 
iodine, iodoform, belladonna, and a host of drugs have been regarded 
as specifics, but, with the exception of digitalis, their action may be 
said to be generally disappointing. 

The following mixture may be tried : 

R. — Morphinse hydrochlor. ..... gr. ij. 

Tinct. digitalis . . . . . . %i], 

Ext, haniamelidis fkl ^ ss. 

Tinct. hydrastis . . . . . . . ^vj. 

Glycerini purif. ad ^iij. — M. 

S. — A teaspoonful to be taken every three hours in water. 



Astringents (when administered internally by the mouth) like alum, 
tannic, gallic, or pyrogallic acids, acetate of lead, sulphuric acid, and 
matico, are so uncertain or inoperative as hardly to be worth trial. 

Speaking generally, the treatment of increased or irregular flow of 
blood from the unimpregnated uterus, by the administration of drugs 
in the ordinary way by the mouth is most untrustworthy when not 
backed up by measures calculated to remove the cause of the affection. 

Local means of checking the hemorrhage may be resorted to when 
the drain upon the system begins to tell upon the patient's strength, 
and when this becomes very evident, local methods must be adopted. 

Electricity, used according to the method of Apostoli, has been found 
in many cases to check hemorrhages which have resisted all treatment. 
The most suitable cases for this remedy will be found in those where 
the hemorrhage is caused by uterine fibroids or by subinvolution. 

The positive pole should always be introduced into the uterus when 
a haemostatic effect is required, and the negative applied externally by 
means of the clay pad. A current of 100 milliamperes is generally 
sufficient, and the seance should not exceed ten minutes, and in fre- 
quency should not be oftener than twice a week. 

The hemorrhage may be often checked, and even permanently re- 
lieved, by this treatment, though there be no diminution produced by 
the electrolysis in the size of the uterus. Where polypi can be easily 
and safely removed by surgical means, it is hardly necessary to say 
that the operation should not be delayed where serious hemorrhages 
continue to tell upon the patient's strength 

When the hemorrhage is the result of the presence of a multinodular 
myoma* the removal of the appendages arrests the growth and lessens 

33 



506 MENORRHAGIA. 

or stops the hemorrhage, but if depending upon the soft, oedematous 
form of myoma, this operation is useless. 

Intra-uterine injections of strong solution of chloride of iron, nitrate 
of silver, pure carbolic acid, creasote, or iodine are sometimes employed. 
Their use is, however, fraught with considerable danger, and should be 
left in the hands of the specialist. When their employment is con- 
sidered absolutely necessary, the cervical canal must be dilated to the 
extent of permitting their flowing backward. 

It is generally advisable to employ a contrivance upon the principle 
of the double-barrelled catheter, which, upon being inserted into the 
uterine cavity, will permit the fluid to flow out through one channel 
after flowing in by the other, and only a very small quantity of the 
liquid (under a low pressure) should be injected. 

When intra-uterine medication is indicated, as a rule it will be found 
much better practice to fully dilate the os and cervical canal with sea- 
tangle tents or other suitable method of dilatation, after which the 
medicinal agent can be freely applied to the interior of the uterus. In 
this way the writer has successfully treated menorrhagia caused by 
subinvolution of the uterus, complicated with a granular condition of 
the lining membrane, by freely swabbing the interior of the cavity 
with fuming nitric acid, as recommended by Atthill. 

Where sudden and alarming hemorrhages come on, threatening the 
patient's life unless prompt action be taken to stop them without the 
loss of time entailed by waiting for the action of the above-named 
plans of treatment, plugging of the vagina may be urgently demanded. 
This performance has been fully detailed under Abortion, upon page 
11. 

It is advisable to always keep before the physicisn's mind the dangers 
and inconveniences which may be expected to follow the sudden check- 
ing of periodical hemorrhages from the uterus about the climacteric 
period. In such cases heroic treatment is very seldom called for. As 
soon as any warning is perceived of a hemorrhage already due or rea- 
sonably expected, a strong saline purge may be given, and in plethoric 
subjects, when time permits, this may be preceded by 5 grains of blue 
pill or 4 grains of calomel. 

After the action of the cathartic and absolute rest in bed, the follow- 
ing pill may be given every four hours : 

R • — Morphinse hydrochlor gr. ^. 

Ext. ergotse gr. J. 

Ext. belladonna gr. £. — M. 

Make 24 such pills. 

When the attack has passed off, a pill may be given every night 
until the next period, and full doses of bromide of potassium should 
be given twice a day during the interval between the hemorrhages. 



MESENTERIC GLAND DISEASE. "507 

MENSTRUATION, Disorders of— See under Amenorrhcea, 
Dysmenorrhcea, and Menorrhagia. 

MESENTERIC GLAND DISEASE. 

The treatment of this affection will in no way differ from that of 
enlarged scrofulous glands in any other region of the body. Under 
scrofula, lymphadenitis, tuberculosis, etc., will be found mentioned, 
among other remedial agents, the following : Change of air and scene, 
by removal to a sheltered seaside resort, protected chiefly from the 
north and east, in which the patient can spend the greater portion of 
his time in the open air, nutritious foods in abundance, especially milk, 
eggs, butter, beef essences, etc., and in some cases, peptonized foods. 

Of all drugs cod-liver oil stands easily at the head of the list. Next 
to it comes malt extract, or the combination of Kepler's extract and 
cod-liver oil, which is one of the most valuable additions ever made to 
pharmacy. Pancreatic emulsion has not maintained the high position 
which its first trials raised, though it is an agent of considerable value. 

Iodides, especially the syrup of iodide of iron with iodide of potas- 
sium, come next in value. Iron phosphates, hypophosphites, arsenic, 
chloride of calcium, etc., are mentioned under Scrofula. 

The writer has obtained results in advanced cases of this affection 
which were most surprising, after all the above had failed, and the 
patients were steadily passing from one stage of emaciation to a worse. 
Indeed, a case of chronic enlargement and matting together of the 
abdominal glands should be far advanced before the physician pro- 
nounces the patient to be beyond the region of hope. It is in keeping 
with our present views to regard all recoveries under these circum- 
stances as if they had been instances of simple scrofulous enlargement 
of the glands, and not examples of genuine tubercular lesions. The 
writer, however, had satisfied himself that from clinical experience 
there are good grounds for believing that tuberculosis, limited to the 
abdominal cavity, is a curable affection. He had arrived at this con- 
clusion from a clinical study of several cases before he became aware 
of Sir Spencer Wells's remarkable experience, where, after he had 
opened the abdominal cavity and finding it studded with tubercles, he 
closed it up and sutured the wound, the patient recovered, and was 
healthy and well several years afterward. The remarkable and numer- 
ous reports of cures following simple abdominal section in tubercular 
peritonitis are among the most striking evidences of therapeutic 
progress. 

The treatment from which he has obtained the highly satisfactory 
results referred to, consists in the steady and persevering inunction of 
cod-liver oil into the skin over the abdomen, the oil being also given 
by the mouth, alone, or with malt extract. 

The inunction should be carried out in the following manner : After 
a w r arm bath, the skin being thoroughly dried by friction with warm 
towels, a tablespoonful or more of cod-liver oil is rubbed in by the 



508 ' METRITIS. 

palm of the hand before the fire into the front and sides of the abdo- 
men, especially into the skin in the inguinal regions. A flannel roller 
is bound over the abdomen, reaching from the pubes to the lower part 
of the sternum. Over this, and covering it in at all points, is applied 
a broad piece of moderately strong mackintosh sheeting. The friction 
should be continued night and morning for the first four or five days, 
the same soiled flannel being reapplied each time. Soon this becomes 
saturated with the oil under the impervious sheeting, and as the little 
patient twists or moves about during the day and night, the oil is 
rubbed in incessantly. After the saturation of the flannel only one 
fresh and free application need be made in the day. The patient's 
clothes or linen are not much soiled, but the odor becomes very objec- 
tionable to the patient's friends, though he soon appears to become in- 
sensible to the discomfort himself. The binder need not be changed 
oftener than once in ten days. 

Though this treatment will be found of the greatest value in ab- 
dominal glandular disease, the writer has used it in various other wast- 
ing diseases in children, with the most satisfactory results, since about 
1873. He has repeatedly witnessed an ascites, warranting a tapping 
operation, to disappear under its use when arising from glandular mis- 
chief. He was encouraged to persevere with it in every case of this 
nature after observing its effects in one instance in an emaciated, scrofu- 
lous child, whose abdomen seemed distended with fluid almost to burst- 
ing, the umbilicus being protruded like the finger of a glove. The 
parents, believing the case to be hopeless, refused, to permit tapping. 
The inunction was, however, persevered with, and after many weeks 
the patient recovered. A large mass of enlarged glands, around which 
the great epiploon was probably matted and adherent, slowly and 
steadily disappeared. The patient is'now a strong, healthy young man. 

It is also somewhat astonishing to see how diarrhoea disappears 
under the steady application of the binder and cod-liver oil in such 
cases, and when constipation exists, it likewise is relieved by the fric- 
tion and pressure. 

METRITIS. 

Metritis and endometritis are most frequently found occurring 
together. The chief indications for treatment are almost identical in 
each case, and, as these have been already detailed under endometritis, 
they need not be detailed here, but for convenience they may be 
briefly formulated. Thus, for the acute form of metritis : 

1. Absolute rest in bed. 

2. The evacuation of the rectal contents by one large tepid enema. 

3. The relief of pain by opium, given by the mouth, subcuta- 
neously, by the bowel as a suppository, or by the vagina as a medicated 
pessary. 

4. Hot fomentations, w«rm water compresses, or hot poultices to the 



METRITIS. 509 

abdomen, in conjunction with local sedatives, as belladonna extract, 
laudanum, etc. 

5. Vaginal injections of large quantities of hot water alone, or con- 
taining a small percentage of pure carbolic acid (1 ounce to 1 gallon.) 

6. Warm or hot sitz-baths. 

7. Leeches to the margins of the anus or over the pubes in severe 
cases, 

8. Antipyretics or diaphoretics to encourage the action of the skin, 
and to reduce the temperature, when this ranges above 102° or 102.5°. 

In acute septic forms of metritis, in addition to the above treatment, 
the interior of the uterus should be washed out with' warm sublimate 
solution, or carbolic iotion (1 : 30), or permanganate solution (2 grain 
to 1 ounce), to remove debris of clots, placenta, etc. In some cases it 
may be necessary to cause dilatation of the os and canal, in order that 
thorough exploration of the cavity may be carried out and the re- 
moval of septic matters effected. The cervical canal should be always 
sufficiently patent to allow the free return of injected liquids, else an 
instrument upon the double-barrelled catheter principle should be 
employed, and the injections may be continued morning and evening 
until fetor diminishes, after which one syringing daily may be prac- 
tised. 

Where a high temperature is present, combined with the symptoms 
such as are met with in puerperal fever, free stimulation and the 
administration of 10 to 15 grain doses of antipyrine every four or six 
hours, until the fever heat falls, or 10 grain doses of quinine, may be 
administered. Failing these, in the presence of hyperpyrexia, the 
cold bath or wet pack may be resorted to. 

The treatment of chronic metritis will depend upon the removal of 
the cause, and as in the majority of instances this will be found to be 
owing to a condition of sub-involution, the factors which prevent or 
retard the uterus from passing into its normal dimensions must be 
carefully sought for. These are — clots, membranes or portions of 
placenta being retained, lacerations, and granular degenerations of the 
lining membrane of the cervical canal, insufficient rest after delivery, 
menstruation or miscarriage, displacements or flexions of the uterus, 
adhesions and the tractions produced by the cicatrization of old in- 
flammatory pelvic troubles, non-lactation, etc. Each of these being 
sought for and remedied or relieved as far as possible, the general in- 
dications as detailed under chronic endometritis (page 242), both con- 
stitutional and local, may be applied. 

In comparatively recent cases following delivery or abortion, the 
free use of iron combined with ergot is of the greatest value. 

Rest is often abused. In the early stages of chronic or in the late 
stages of acute metritis it is essential, but the prolonged rest inflicted 
upon patients suffering from essentially chronic forms of the disease, 
in the long run is productive of mischief by weakening the general 



510 MOLE PREGNANCY. 

tone of the system and encouraging the passive congestion of the 
organs in the pelvis which is at the root of the evil. 

The introduction of a comfortably-fitting ring or Hodge pessary, 
which will support and steady the uterus and permit the patient to 
indulge without pain in moderate open-air exercise between the men- 
strual period, is of much value. Rest, while menstruating, as a rule, 
is advisable. 

Hot vaginal injections followed by cold alum solution, sea bathing 
when the patient's symptoms do not contra-indicate it, and the free use 
of saline cathartics, may be tried. 

In very chronic cases much good may be obtained from full doses of 
the iodide of potassium, alone or combined with the bromide. 

Locally, congestion may be relieved by periodically inserting plugs 
of cotton w T ool saturated with glycerin into the vagina, and allowing 
them to remain for twenty-four or forty-eight hours. Involution may 
be hastened by frequent applications of iodine, carbolic acid, or other 
antiseptic counter-irritants applied to the os, cervical canal, or interior 
of the uterus upon Playfair's probes. Blistering fluid and scarifica- 
tions have been found useful for the same purpose when applied to 
the cervical canal. Emmet's operation, and amputation of the poste- 
rior lip of the os or of the cervix, is often found to stimulate the uterus 
to healthier action, and thus to lead to a diminution in its size. (See 
also Endometritis, page 213.) 

MIGRAINE— See Megrim. 
MISCARRIAGE— See Abortion. 

MOLE PREGNANCY. 

As soon as the diagnosis has been made clear by the escape of some 
of the characteristic vesicles or fluid contents of the uterus and there 
is any evidence of hemorrhage, the physician should proceed to remove 
the uterine contents without delay by dilating the os by means of 
Barnes's bags. At the same time ergot should be given in full closes. 

Where hemorrhage is copious, plugging may be performed until the 
canal or os is sufficiently dilated to admit the dilator or finger ; in 
some cases a laminaria tent may be .necessary. After the dilatation 
has been accomplished, in the absence of uterine pains following the 
internal administration of ergot, ergotine should be given hypoder- 
mically, and the uterus emptied by expression from above, after which 
the case may be treated as one of premature birth or abortion. 

Though it is highly desirable that all the diseased products be 
removed from the uterus, nevertheless it is not advisable to insure 
this by internal manual, or instrumental means, if possible, as there is 
danger of serious structural alterations having taken place in the 
uterine w r alls in some cases. For similar reasons the prolonged admin- 
istration of a mixture containing ergot, quinine, and strychnine may 



MOLES— MOLLU&OUM COXTAGIOSUM. 511 

be indicated, with the view of producing steady contraction and hasten- 



ing involution. 



K .—Ext. ergots? fld. 
Quininae sulph. 
Tinct. nucis vomicae 
Tinct. digitalis . 
Tinct. aurantii amar. 



gr. xxx. 
3iv. 



S. — A dessertspoonful to be taken four times a day in water, before meals. 

MOLES. 

Moles, or hypertrophic growths of the skin, generally of congenital 
origin, may be removed, when the cause of deformity, by the applica- 
tion of caustics, and when of large dimensions by the knife, cautery, 
or Volkmann's spoon. Caustic potash, made liquid by the addition of 
a little water or chloride of zinc, may be painted over the mole and 
allowed to scab over. The ethylate of sodium and nitric acid are also 
used. Any caustic, indeed, may be employed which the experience of 
the surgeon gives him confidence in manipulating and managing, 
Very large marks should be operated upon in small sections at a time, 
the region submitted to destruction being allowed to heal before a new 
portion is attacked. 

MOLLITIES OSSIUM. 

In writing about the treatment of a disease like the present, it is the 
stereotyped thing to say that every departure from health in digestion, 
appetite, sleep, rest, etc., is to be corrected, and the general tone of the 
system improved by rest, good food, fresh air, and tonics, etc. No more 
in this respect can be said for the general treatment of mollities ossium 
than of other grave conditions, and about its special treatment nothing 
can be said, for practically nothing is known. Absolute rest is essential, 
and since the disease is nearly always associated with pregnancy, the 
question of inducing very early labor will often thrust itself upon 
the physician, though the fact must not be lost sight of that where 
the disease is still in progress the pelvis is almost certain to be 
dilatable. 

Unfortunately, however, if the gestation be permitted to go to full 
time the pelvic outlet may be found dilatable, while the brim is unyield- 
ing, in which case Cesarean section may be demanded. 

MOLLUSOUM CONTAGIOSUM. 

The only treatment of any use in the majority of instances consists 
in the removal of the small cystic growths. Hutchinson finds that, if 
seen in the very early stages, frictions with equal parts of the ointments 
of white precipitate and sublimed sulphur will effect their removal. 
When upon the face, a small incision with a fine tenotomy knife and 



512 MOLLUSCUM FIBROSUM — MUMPS. 

the thorough evacuation of their contents are all that is necessary. 
Upon the body, they may be snipped out by scissors or the knife, or 
when very small aud numerous they may be destroyed by ethylate of 
sodium solution, pure carbolic acid, nitric acid, or other caustic. When 
very large, a free incision into the cyst may be made, the contents 
squeezed out, and the cavity curetted. 

MOLLUSCUM FIBROSUM. 

Excision by the knife and forceps, by the elastic ligature, by scissors, 
or by the galvano-cautery, is the best practice. Where the tumor is 
large the ecraseur may be necessary. The method of electrolysis by 
using the needle, as in the destruction of small nsevoid growths, has 
been found to succeed without causing any mark after the shrivelling 
up of the tumor. 

MORPHINE HABIT— See Opium Habit. 

MOVABLE KIDNEY. 

No treatment is called for in most instances where a movable kid- 
ney exists ; but when severe pain and inconvenience follow the dis- 
placement of the organ the patient should lie down and rest in the 
horizontal position, with the head low and the pelvis slightly raised. 
In one case the writer found a patient writhing in an agony and 
screaming for relief, urine being voided in drops, owing to most severe 
tenesmus, which came on very suddenly, after some exertion. The 
presence of a floating kidney being suspected from a previous exam- 
ination, without waiting for chloroform, morphine hypodermically, hot 
stupes, or the usual methods of allaying formidable spasm, he imme- 
diately caught the patient by the heels and thoroughly inverted the 
body. Instant relief followed. 

Recurrence of such attacks may be prevented to a great extent by 
applying a firm bandage over the abdomen after the organ has been 
restored to its normal position, and if the parieties are very much 
relaxed, as in those who have borne a large number of children, a 
hard or smooth inelastic pad may be placed over the movable kidney, 
and a skilfully made abdominal belt constantly worn. 

Niehans has devised a truss which, in some instances, may be found 
very useful. 

Stitching of the movable organ to the abdominal walls has been 
successfully accomplished, and even extirpation has been performed. 

MUCOUS PATCHES OR TUBERCLES.— See Condylomata. 

MUMPS. 

The treatment of this affection is very simple, and were it not for 
the fact that orchitis or meningitis and, according to some authorities, 



MYELITIS. 513 

ovarian and mammary inflammation has been found to supervene, 
nothing whatever might be done. The chief indication is to keep the 
patient protected from draughts, and the swollen region covered by 
warm, dry dressings. A pad of absorbent cotton wool, covered by a 
layer of oiled silk, is all that is necessary in most cases. Where the 
tension gives rise to great pain and inability to open the jaws, a hot 
fomentation or warm poultice may be applied, but cold lotions had 
better not be employed. Extract of belladonna may be smeared over 
the face of the poultice. Should the pain continue, with throbbing 
and local increase of temperature, suppuration may be feared, though 
the event is rare, and in this case continual poulticing with warm or 
hot fomentations should be persisted in until the presence of matter is 
rendered certain by fluctuation, when a free incision should be made, 
and the wound treated by antiseptic lotions. 

Owing to the difficulty of opening the jaws, fluid nourishment is 
essential for several days until the swelling subsides. Where there is 
much increase of temperature and constitutional disturbance, a mixture 
like the following may be given : 

& .— Tinct. aconiti TT[ x. 

Liq. ammon. acet ^j. 

Tinct. croci 3j. 

Aquae campli. ....... ad ^ij — M. 

S. — A teaspoonful to be taken every second hour. 

The complications are to be treated upon general principles, and 
there is still among the older practitioners a belief in the metastatic 
nature of the orchitis, meningitis, or ovaritis, which leads them to 
apply a smart sinapism or sharp counter-irritant to the parotid region 
when they notice signs of metastasis. 

MYALGIA— See Rheumatism, Muscular. 

MYELITIS. 

The treatment of this affection will for the most part embrace the 
management of whatever factor has caused the inflammation of the 
cord, as often the myelitis will be found to be secondary to injuries, 
wounds, diseases involving the spinal structures, hemorrhage, or spinal 
leptomeningitis. From whatever cause, rest as near to being absolute 
as possible should be insisted upon from the onset of the first symptoms. 
The best position is the horizontal. The nursing is of the utmost im- 
portance, and a water bed is of greatest use, and in some instances it 
is essential for the prevention of bedsores. 

Cold to the spine by means of the spinal ice-bag is the safest remedy 
which our present knowledge can supply. Where there is great pain 
and tenderness a dozen leeches may be applied in two or three places 



514 MYOPIA. 

on each side of the spine, and, after they fall off, cupping-glasses may 
be applied over the bites with great advantage in some cases. The 
cautery or blisters are sometimes recommended. 

Drugs are not to be much depended upon in acute cases, but some- 
times mercury has been found to do good. It should be given in small 
doses, and the bichloride is the best preparation. Salivation by inunc- 
tion is contra-indicated in the great majority of cases. Ergot, though 
theoretically indicated, has rarely been found to do much good. More 
may be expected from large doses of iodide of potassium. 

Galvanism is indicated after the acute symptoms pass off. The con- 
tinuous current from fifteen Leclanche elements may be used by placing 
one large moistened electrode over the cervical spines, and the other 
over the lower part of the spinal column. The electrodes should be 
not only thoroughly saturated with liquid, but they should be warm. 
A strong solution of common salt in hot water answers perfectly. Ten 
minutes will be long enough for each seance. The electrodes should 
be moved up and down the spine, and the applications need not be 
more frequent than twice in the day. 

At a later stage massage and faradization of the wasted muscles, 
with phosphorus by the mouth, and strychnine injected into the mus- 
cular substance or subcutaneously, may be of the greatest benefit. 

The treatment of bedsores, which are so prone to occur, is of the 
utmost importance, and the remedies which are available will be found 
under Bedsores. The state of the bladder will require the closest 
attention, and fetor in the urine should be instantly met by the internal 
administration of 10 grain doses of boric acid. With this remedy the 
washing out and injection of the bladder by antiseptics is now gener- 
ally unnecessary. The softer rubber catheter lubricated with glycerin 
of borax should, when possible, be used to relieve retention of urine. 

MYOPIA. 

Attention should be paid to the amount and nature of the work im- 
posed upon the myopic eye. If more attention was paid to the printing, 
type, and paper entering into the ordinary school-books, and if the 
" result fees " system was done away with, there probably would be less 
myopia. Where pain or aching follows the use of the eyes all school 
work should be given up entirely for a short period, and after the com- 
plete rest has removed these symptoms, shorter school hours, better 
print, and clearer light should be provided. 

The optical treatment will consist in the proper selection of suitable 
concave glasses. These will consist in spectacles or eye-glasses for dis- 
tance and for reading. These latter, as a rule, are better to be a little 
more than half the full correction, except in very low degrees of myo- 
pia, when glasses which fully correct the error may be used. In the 
higher degrees it is a good plan to disorder the accommodation by 
instilling atropine, so as to prevent the otherwise powerful efforts at 
accommodating. In very mild cases, resulting from overwork, especi- 



MYXEDEMA. 515 

ally when the eyes have been long and persistently fixed upon minute 
objects, and where myopia may be said to be commencing, the proper 
treatment will be to insist upon proper rest to the eyes and the instil- 
ling of a drop of weak eserine solution every night for a couple of 

months. 

MYXCEDEMA. 

As the pathology of this rare and highly interesting affection is being 
steadily cleared up, there is some light at length being thrown upon its 
treatment. By measures directed to the general health, and to those 
agents which improve the appetite and digestion, much may be done 
to prolong life. It is of considerable importance that the functions of 
the skin should be most carefully attended to, and the patient should 
be clad in flannel from head to foot. It is a significant fact that in 
those cases where remedial agents have been found to retard the prog- 
ress of the disease, their rationale may be explained to a great extent 
by their diaphoretic action. Thus, the various forms of hot, warm, or 
vapor baths persistently employed have been followed by improvement, 
and Ord and Sir Andrew Clarke have met with such results. 

Jaborandi, in full doses, has caused the symptoms almost to disappear 
in the experience of Ord. 

Arsenic, chloride of gold, and other alteratives have been unsuccess- 
fully tried. Many able workers at home and abroad have been labor- 
ing in this interesting portion of the field of therapeutics, and the results 
are highly interesting, and promise to throw considerable light upon 
the pathology of the disease. Thus, Horsley, independent of Bircher 
and Kocher, has pointed out the value that might possibly accrue in 
operative myxoedemaor cachexia strumipriva by transplanting normal 
thyroid tissue. The suggestion has been put to the test of experiment 
with results that warrant a hope of the possibility of curing myx- 
oedema. 

" In a case where a severe form of the disease followed the uninten- 
tional removal of the entire thyroid gland, Bircher transplanted into 
the abdominal cavity a portion of the tissue (which appeared to be 
normal) from a goitre, improvement set in and was maintained until 
atrophy of the graft took place. The operation was afterward repeated, 
and the future of the case will be followed with interest. Meanwhile, 
the benefits of transplantation have been established. Horsley points 
out that with our recently acquired knowledge of the functions of the 
thyroid, the cachexia strumipriva will, of course, disappear as the opera - 
tian of entire excision is abandoned, and he believes the operation of 
transplantation will be always indicated in ordinary myxcedema and 
sporadic cretinism. 

Where it is better to transplant goitrous human tissue or healthy 
thyroid from lower animals into the abdominal cavity, loose or attached 
to some part of the parieties, is yet to be settled. Lannelongue has 



516 N^VUS. 

recently transplanted sheep's thyroid into the subcutaneous thoracic 
tissue of a cretin with results not yet determined. Recently, an extract 
from the sheep's thyroid has been successfully injected hypodermically. 

NiEVUS. 

The treatment of these growths is capable of endless variations, but 
before any operative measures be determined upon, due consideration 
must be given to the fact that many of these marks disappear after 
spontaneously shrivelling up. Where the nsevus is small, superficial, 
and upon the trunk or covered parts of the limbs, it may be left as 
long as it remains stationary. Even when on exposed parts, an opera- 
tion should be only decided upon after waiting some time, unless the 
growth is deep or showing signs of spreading, or where it is unsightly, 
and has remained so for so long a time as to negative the hope that 
spantaneous cure may result. 

The means of treatment to be adopted will depend upon the size, 
depth, and locality of the nsevus. Thus, when situated upon the 
trunk, some method which will effect' its speedy removal without much 
regard to the size of the cicatrix, is to be preferred to the slow and 
often tedious plans, which, for the sake of sightliness, must be selected 
when the face is the seat of the affection. If the surgeon determines 
to attack the growth without destroying or cutting the skin, a host of 
plans have been tried and recommended, many of which, such as 
pressure by bandaging, or by the constricting effect of painting on 
collodion and astringents, by applying cold by means of ice, ether 
sprarly etc., are utterly useless. 

. Measures with the. view of exciting adhesive inflammation or coagu- 
lation of the contents of the tumor, so as to seal up the vascular tissue 
of which it is composed, offer many advantages. Those will be enu- 
merated which have most frequently been found successful. 

Blistering by cantharides, croton oil, tartar emetic, chloral, corro- 
sive sublimate in strong solution, saturated alcoholic solution of iodine, 
or strongest liquor plumbi has been practically abandoned in the face 
of surer methods ; and the same may also be said with nearly equal 
truth of the old method of vaccinating the child with vaccine lymph, 
over the situation of the nsevus. 

The method of injecting various substances into the interior of the 
tumor to cause coagulation or inflammation, at one time so much 
praised, is now steadily becoming obsolete, owing to the great danger 
of injecting the agent into the circulation and causing sudden death 
by the formation of emboli. Solution of iron, iodine, ammonia, tannin, 
nitrate of silver, and pure carbolic acid, creasote, or absolute alcohol 
have all been tried, and by most surgeons rejected, notwithstanding 
the recommendations to apply a clamp or ring round the nsevus, or to 
break up the interior of the tumor with needles, in order to prevent 
such accidents. 

Of much the same nature is the plan of inserting setons or irritants. 



N^EVUS. 517 

as threads and hot needles, into the tumor, and the result is, though 
loss dangerous, about equally unsatisfactory. 

The only really reliable and unobjectionable method of exciting coagu- 
lation in the tumor is by electricity, and it affords, after all, by far the 
most satisfactory all-round plan of treating mevoid growths with safety 
and with the minimum of disfigurement. It is generally spoken of as 
the electrolytic method, or the method by electrolysis ; but, as pointed 
out by Duncan, this is a misnomer, for whether the results are 
obtained by neurotic, vascular, trophic, or osmotic action, it is not by 
the decomposition of fluids and solids at the poles of the battery as in 
A postoli's plan of treating uterine fibroids. The writer has seen the 
true electrolysis used many years ago (1873) for nsevoid growths, but 
the result was complete failure. 

The best way to proceed to insert a needle connected with the posi- 
tive pole of a battery consisting of ten large Leclanche cells. The 
needle should be insulated, and after being once introduced through 
the skin, need not be removed or withdrawn until the operation is com- 
pleted, but its point can be moved about so as to submit the different 
parts to the electrical influence. The hand of the operator holding 
the needle should not be depressed while the current is flowing, as it 
is desirable that the point of the needle should not reach or penetrate 
the delicate cutaneous covering of the neevus. The kathode is placed 
upon the healthy skin just outside the margin of the growth, and in 
this way, by inserting only one needle, the minimum of scarring is 
secured, especially as it is found almost impossible to insulate the 
needle so completely as to prevent injury of the skin. When too 
strong a current is used, or when the negative pole is introduced, the 
puncture may remain as a disfiguring brown spot. It is at first 
advisable to begin with five or six cells. The length of the seance 
will depend much upon the size and nature of the growth. Some 
small nsevi may be caused to shrivel up and disappear after one appli- 
cation of the current for a few minutes. The operation should be 
concluded as soon as the skin appears to swell up a little, and the color 
of the tumor changes to a dusky hue, when the needle may be rotated 
slightly between the finger and thumb before being withdrawn, a little 
collodion being painted over the puncture. 

The number of application can only be determined after watching 
the results. As a rule, these are much better when the progress of the 
case is allowed to proceed at a slow pace. Once a week may be tried, 
or, if the nsevus is very large, a different part of it may be submitted 
to the action of the current every three or four days, but it will be 
well occasionally to leave long intervals between the applications in 
order to encourage the slow contraction of the vascular walls. 

Some operators prefer to introduce two needle into the growth, one 
being attached to the negative and the other to the positive pole of the 
battery, and some surgeons prefer to work the negative pole owing to 
the greater intensity of its action, and different metals are sometimes 



518 NjEvus. 

recommended, but, as a rule, for ordinary small nsevpid growths the 
insertion into the tumor of an insulated steel needle connected with 
the positive pole is the best for all practical purposes. As already 
remarked, there is no advantage in using a strong current which 
decomposes or electrolyzes the contents of the tumor, as recommended 
by some who use Stohrer's battery. In this way not only ordinary 
nsevi, but deep and extensive cavernous angeiomata and cirsoid aneu- 
risms may be effectually dealt with which are beyond the reach of art 
by any other method. Port wine marks are, however, little influenced 
by electrolysis. 

Ligature, though generally successful, is a very painful operation, 
and the various plaus of subcutaneous ligature are not always satis- 
factory. The destruction of tissue is so extensive, and the subsequent 
cicatrix so unsightly, that about the face the operation should not be 
undertaken, especially as the contraction of the cicatrix may seriously 
interfere with the normal positions of the eyelids and lips. 

Upon the trunk the writer has employed the ligature with good 
results by passing underneath the 'growth two hare-lip pins at right 
angles to each other, and tying firmly the tissues by a stout silken 
thread, after which the pins may be immediately withdrawn, though 
he prefers to leave them in situ for twenty-four hours. After the 
strangulated growth falls off, the raw surface may be treated as an 
ordinary sore by antiseptic dressings. 

Destruction of the growth by the application of such caustics as 
chloride of zinc, potassa fusa, Vienna paste, arsenic, etc., is most pain- 
ful and unsatisfactory, and should only be undertaken in very excep- 
tional cases. The same remark applies to the use of the actual or 
thermo-cautery, and to the method of inserting needles, which are 
afterward to be heated by a spirit lamp. 

Nitric acid may, however, be painted over very superficial nsevi 
with success. Ethylate of sodium has been introduced as a remedy 
for the treatment of nevoid growths, and as there appears to be much 
uncertainty or difference of opinion regarding the methods of using it 
to best advantage, it may be advisable to quote the words of Richard- 
son himself. The writer has successfully employed it for the destruc- 
tion of small cutaneous or superficial growths. 

"As a rule, I employ the sodium ethylate in practice, but I have 
many times employed the potassium salt in cases where it was import- 
ant to destroy a structure very promptly. Whichever of the prepa- 
rations is employed it should be in a solution made by saturating the 
alcohol with the element until a solution of sp. gr. 0.880 is obtained, or 
by the addition of absolute alcohol to the crystallized salt until a 
solutionis made of the same specific gravity. This solution should be 
kept in a cool place, apart from the light. Originally I recommended 
that a glass rod should be used in applying the solution, and with the 
potassium ethylate this is still advisable, but with the sodium solution 
it is not necessary. A good camel's hair pencil is all that is required. 



N^EVUS. 510 

In treating nsevi I first dry the surface with a piece of cotton-wool ; 
then with a brush I thoroughly coat the dried surface with the solution. 
The application causes always some effusion and redness, accompanied 
by a little pain, expressed by those who are old enough to describe it 
as a burning sensation like the sting of a bee or of a nettle. After a 
short time there is an exudation of water, in drops, from the red sur- 
face, which exudation lasts for a few minutes, and is followed by dry- 
ness and sometimes by pallor or duskiness of appearance. In the 
course of four or five hours a scale begins to form, and continues until 
there is quite a hard crust, which completely covers the nsevus, but 
through which the soft vascular character of the swelling can be 
detected. Originally after it was formed I allowed the crust to remain 
for a few days, then removed it with a wire scoop, and re-applied the 
solution o^r the red surface. The proceeding led to a rapid cure, 
but it was so painful as to demand the use of a general anaesthetic. 
I have therefore, given this up for a mild and sure, but rather slower 
method. After the first crust is fully formed I pass through it, on the 
third day, a fine needle, with cutting edges shaped like the old cata- 
ract needle, and with this I break up the vascular surface underneath, 
and on withdrawing the needle make firm pressure with lint on the 
upper surface. A large drop or two of blood flows out freely, but 
further escape is easily controlled by a dossil of lint charged with 
styptic colloid. When the bleeding has quite ceased a drop of ethylate 
solution is inoculated into the nsevus through the punctured opening, 
a new layer of it is painted over the crust, and the crust is left as it 
was. The crust may be left four days more, and if at that time the 
vascular softness still remains under it, it must be treated by puncture 
and re-injection just as before. When at last the crust feels firm and 
dry beneath, the cure may be considered as complete, and the crust 
may be left to scale off by itself leisurely. In the treatment of raised 
nsevus by this plan I have never seen the least untoward symptom of 
moment, and although some cases have been rather more tedious than 
others, there has not been one failure of cure. In fact, I have come to 
look upon the method as specific for the ordinary raised circumscribed 
nsevus. In respect to the smooth, diffused nsevus, commonly called 
" mother's mark " or " port wine stain," I have not so good a report to 
offer." 

Excision or enucleation may be practised with much advantage in 
the case of nsevi upon the trunk. The loss of blood is for the most 
part trifling, some growths shelling out without any hemorrhage. The 
results are rapid and satisfactory. Where the nature of growth 
appears to be arterial, or where there is suspicion of an element in it 
of aneurism by anastomosis, if the knife be at all used it must sweep 
clear of the growth. 

NAILS, INGROWING. See page 398. 

NASAL POLYPUS— See Polypi. 



520 NECKOSIS. 

NAUSEA— See under Vomiting-, Dyspepsia, etc 
NECROSIS. 

The cause of the bone mischief must receive attention from the 
first. If, for example, syphilis has been the probable starting-point, 
remedies directed to this affection should be administered. Antistru- 
mous remedies are indicated in a large percentage of cases, and when 
the lower jaw is the seat of the necrosis from phosphorous fumes, the 
patient should be urged to give up his occupation. As the drain upon 
the system is certain to be both severe and long, attention should be 
most carefully paid to the diet, purity and abundance of air, and 
proper rest. When abscesses form they should be opened early. This 
is especially true when the matter forms under the periosteum. The 
incisions should be free and deep. With these measures— i. e., rest, 
feeding, opening of abscesses, the remedies directed against the primary 
cause the disease — the surgeon must wait while nature performs her 
part in separating the living from the dead bone, operative interfer- 
ence at this stage being bad practice." Where the sequestrum is super- 
ficial, as in exfoliation, its removal is easily accomplished by enlarging 
the sinus and incising the soft parts, when it may be grasped by a 
stout pair of dressing or necrosis forceps, or it may be pried out of its 
bed by inserting a strong probe or director under its freest extremity.,^ 

When the sequestrum is central or lying free in the interior of a 
long bone, surrounded by dense ivory-like tissue, its removal may 
present serious difficulties. The writer has seen a large loose seques- 
trum in the shaft of the femur defy the skill of several surgeons. In 
such cases Esmarch's bandage being applied, under chloroform the 
sinuses in the soft parts may be slit up freely, so as to thoroughly 
expose the cloaca? in the healthy bone. These must be enlarged before 
any attempt can be made to extract large sequestra, the gouge, chisel, 
and mallet, or the bone forceps may be used, but in many instances it 
will be better to trephine in the neighborhood of the two largest 
cloacae and connect the apertures so produced by two parallel incisions 
made by means of a Hey's or a straight saw. In this way a small 
quadrilateral plate of bone with concave extremities may be removed, 
leaving a little window in the healthy shaft, through which the seques- 
trum can be pulled out. Should the sequestrum refuse to be dragged 
or extracted through this opening, it may be seized in its centre by a 
pair of cutting bone forceps, and divided in two or more pieces which 
are easily removed by dressing forceps. 

The smooth cavity out of which the dead bone has been extracted 
may be plugged by iodoform or sublimate gauze, to restrain the hem- 
orrhage which occurs after the removal of the Esmarch's bandage. 
The wound is then treated upon antiseptic principles, and recovery is 
generally rapid and satisfactory. As a rule, it may be said that 
unnecessary injury to the healthy bone is more likely to follow pro- 
longed attempts at extracting the sequestrum through narrow cloaca? 



NEURALGIA. 52 1 

than by the free division carried out by means of the trephine and 
saw. The writer at one time had considerable experience of this 
operation in a children's hospital, and never saw any permanent 
weakening of the limb follow the use of the trephine and saw. (See 
treatment of Acute Necrosis under Periostitis.) 

NEPHRITIC COLIC— See Stone in the Kidney. 
NEPHRITIS— See under Bright' s Disease. 
NEPHROLITHIASIS— See Stone in the Kidney. 
NETTLE RASH— See under Erythema. 

NEURALGIA. 

The treatment of neuralgia will resolve itself in the first place into 
the removal of the cause, when this can be discovered, and with this 
object in view the physician must search diligently for any departure 
from the ordinary healthy standard, and having found it he should 
proceed at once to correct it with the hope that its removal may be 
followed by the disappearance of the nerve trouble. Such rational 
treatment in no way interferes with the various methods by which pain 
is to be relieved. It cannot be too strongly stated that though the 
temporary relief of suffering should play an important part in the 
treatment of the various neuralgic conditions, it should not be regarded 
as the chief or sole principle upon w T hich the physician should approach 
the management of a case of severe neuralgia, though it is true that he 
may find in some cases no other indication for treatment. 

It is also not to be lost sight of that smart neuralgia may persist after 
the removal of the cause, which, in the first instance, induced the 
neuralgic condition in the nerve trunk or its branches, and this con- 
sideration should prevent the very common mistake of flying from one 
remedy to another in quick succession without waiting a sufficient time 
for that steady and continuous action of the drug which may be 
crowned by permanent success. It is only after the evident failure of 
sucli rational treatment, that the scientific physician will feel justified 
in resorting to the various empirical methods which experience may 
lead him to hope as likely to prove useful. 

Among the departures from health standing in the relation of 
probable causes of neuralgia is anaemia. It is the experience of every • 
physician that anaemia and neuralgia often occur together, and that no 
treatment sometimes will give any permanent benefit until the anaemia 
is removed, hence in every such case iron is indicated. The scale 
preparations, the tincture, saccharated carbonate, Blaud's pills, or 
other preparation may be given according to the special indications 
present. Occasionally, indeed, it may be necessary to give one prepara- 
tion for a time, and follow it up by another until the system is saturated 
with iron. As a rule, small doses of iron are useless, and in this 

34 



522 NEURALGIA. 

respect the treatment of neuralgia by iron preparations is upon the 
same footing as is that of chlorosis, in which affection doses much 
greater than can be assimilated appear to be necessary to produce the 
best results. In another important respect chlorosis and neuralgia 
agree — the treatment must be continued for a considerable period after 
the symptoms of the diseased condition have passed oft', otherwise 
relapses are almost certain to occur. 

The following pills may be given for a considerable period : 

R. — Ferri reducti gv. iv. 

Quininae sulphatis ....... gr. ij. — M. 

Make 24 of these pills. 

S. — One pill to be taken three times a day after meals, and two to be taken 
at bed hour. 

Arsenic is a drug of the greatest value in neuralgia, especially in the 
very chronic or obstinate forms. Like iron, it must be given in full 
doses for long periods, and be continued for a considerable time after 
the painful paroxysms have passed off. It is, moreover, a valuable 
drug in cases not characterized by marked anaemia, and the writer 
generally gives it in combination with iron, or during the intervals 
when the administration of iron is suspended. The arseniate of iron 
may be given in a pill in doses of i grain in combination with quinine, 
or it may be added to the above formula. 

Errors in nutrition must be remedied by improved dieting, by the 
administration of large quantities of nourishing food as often as the 
appetite and digestion will permit. Every means whereby these latter 
can be improved is to be carefully attended to, by tonics and pepto- 
nized foods when necessary. Some cases of neuralgia which have 
resisted all treatments have been known to yield to overfeeding. 

Massage, in as far as it powerfully stimulates appetite and digestion, 
is a valuable aid in the treatment of neuralgia, 

Insomnia, diminished amount of sleep, the fagging of overwork, high 
pressure, grief, and anxiety demand prompt and radical measures 
before the ordinary routine remedies can have a fair chance. 

Gouty, rheumatic, or malarial conditions of the system should be 
met by alkalies, colchicum, salicylates, iodides, salol, quinine, or other 
recognized agents. Syphilis is to be met by mercury. Lead poisoning, 
which not infrequently is the cause of neuralgia, calls for appropriate 
management, in which iodide of potassium should hold a prominent 
place. 

Menorrhagia and uterine mischief may be the cause of abdominal 
and other neuralgias. Sources of irritation, which by reflex action 
may be the exciting cause, should be diligently sought for. Thus 
affections of the ear and nasal bones, or the irritation of carious teeth, 
may cause neuralgia of the ^fth nerve, while rectal, anal, or pelvic 
irritation may give rise to sciatica. The effects of cold and damp 



NEUKALGIA. 523 

applied to any region of the body may excite neuralgia in distant 
nerves. Thus wet feet may induce facial pain, and, as a general rule, 
warm clothing and the avoidance of sudden variations of temperature 
are of as great importance in the management of neuralgia as is an 
abundance of pure fresh air and sunlight, with outdoor exercise and 
freedom from worry, or other source of nerve exhaustion. 

The treatment of pain during the paroxysms will call for prompt 
and powerful anodynes. 

Morphine or opium and their preparations are foremost among 
these. To be of use in relieving the pain of an attack, the narcotic 
should be given in a full dose. It may be administered by the mouth 
or hvpodermically ; the latter method is decidedly to be preferred. 
When the affection is not of long standing, there is some reason to 
hope that morphine may prove curative. The experience of every 
physician shows that in a small percentage of cases pain does not re- 
turn after being once subsided by a good opiate, and there are strong 
reasons for believing that this is the result of the opiate, and that the 
cessation of pain is not owing to the natural decline of the disease. 
The writer has several times satisfied himself of the truth of this state- 
ment, especially when treating neuralgia of the sciatic nerve. 

Another important fact may be here emphasized — i. e., that this 
happy and desirable result is more likely to happen when the opiate 
has been injected into the immediate vicinity of the affected nerve than 
if administered by the mouth. In closely examining this statement, it 
may be fairly supposed that the acupuncture is an important element 
in the treatment, since excellent results have sometimes been obtained 
by simple puncture of the affected nerve trunk by a stout needle. 

Acting upon this theory of the duplex nature of the action of the 
hypodermic method of treating neuralgia, the writer has obtained most 
encouraging results by combining the acupuncture and opiate treat- 
ments more closely than is ordinarily attempted. Thus he takes a 
quantity of solution of morphine (1 : 10) for hypodermic use, say 4 
minims, and dilutes this with the full of the ordinary syringe of dis- 
tilled water, making in all 20 or 30 minims of liquid. This he injects 
in several places deeply along the course of the affected nerve, aiming 
at a puncture of the nerve trunk at each insertion of the needle, which 
should be made at right angles to the surface when the nerve lies deep. 
In sciatica, he is certain that this is the best of all methods of treat- 
ment. 

Where this plan is likely to succeed, the result will soon be evident, 
and the physician must be always upon his guard, lest the opium habit 
becomes established during the management of a case of rebellious 
neuralgia by powerful anodynes. This much can be said for the plan 
now advocated — that the risks of the opium habit are decidedly less 
than if the drug be administered by the mouth, or by the hypodermic 
method as usually practised. 

Another important advantage can be claimed for it — viz., that during 



524 NEURALGIA. 

the intervals between the paroxysms any of the numerous methods of 
treatment about to be mentioned can be pursued without let or hind- 
rance. The plan of administering opiates during the intermissions, as 
advocated by some, is not to be recommended ; but when the attacks 
of pain are known or expected to come on at a certain hour, they may 
be occasionally forestalled by a full opiate administered by the mouth. 
The opiate may also be combined with some other remedial agent, as 
quinine, chloride of ammonium, etc. 

Before proceeding to detail the numerous other plans of treating 
neuralgia which might accompany or follow the use of opiates, it will 
be more convenient to briefly review the list of drugs which have been 
from time to time employed in the treatment of this affection ; and in 
detailing their uses, unless when otherwise stated, neuralgia of the face 
is supposed to be the condition generally before the writer's mind. 

Chloride of ammonium may be taken as the type of the so called 
neuralgia specifics. It has been found by experience that full doses 
have the power of relieving the pain and preventing the return of the 
paroxysms in some instances of facial neuralgia. How it acts in some 
and why it fails in the majority of cases we do not know, nor can we 
tell in what cases it will prove successful until it is tried. The same 
remarks will apply to almost the entire list of anti-neuralgic remedies ; 
and in severe and obstinate cases of the disease the physician will be 
obliged to humiliate himself and become a mere empiric, prescribing 
one drug after another until he finds the one which removes the affec- 
tion. Twenty grains in solution may be given every two hours for three 
doses, then every four hours, and as a rule, if relief be not obtained in 
twenty-four or thirty-six hours, the remedy may be abandoned. It has 
been found useful in some instances of intercostal, visceral, and sciatic 
neuralgia, and may be given in combination with the following : 

Quinine, as already mentioned, should be employed in neuralgia of 
malarial origin. It is, however, often of the greatest service in cases 
where there is no reason to suspect malaria, and with some physicians 
it is the first remedy which they prescribe in all cases, no matter what 
nerve may be affected. If there be any special indication for its use, 
it may be said to be most likely to prove successful in those neuralgias 
which tend to exhibit some element of periodicity, though not necessa- 
rily of malarial origin. Less than 5 grains is useless, and 10 grains 
may be given every 6 hours in wafer paper. As a rule, it is not neces- 
sary to push the drug until cinchonism is produced, but in obstinate 
cases this may be done before giving up the remedy. 

By giving it before the expected paroxysm, this may sometimes be 
effectually forestalled. This result is, however, more likely to be ob- 
tained in malarial cases. In neuralgia of the supra-orbital branch of 
the fifth nerve, quinine is perhaps the best remedy which we possess ; 
and in patients who cannot tolerate the drug well, 1 grain may be 
given every forty minutes in solution until five or six doses have been 
administered. 



NEURALGIA. 525 

The following mitrailleuse may be tried in obstinate cases : 

R. — Quimnse sulph. gr. v. 

Morphine hydrochlor gr. £. 

Ammonii chlor. gr. xv. — M. 

S. — One powder, wrapped up in moistened wafer paper, to be taken every 
six hours, after food. 

Antipyrine, antifebrin, phenacetin, and salol may be given 
in all forms of neuralgia, and sometimes they act with remarkable 
rapidity, though the same success is not to be expected as in the treat- 
ment of migraine. 

Ten grains of antipyrine may be given as soon as the paroxysm 
begins, and 5 grains every two hours afterward for three or four doses. 
As a rule, if relief is to be expected at all, it will follow before 20 or 
30 grains have been administered. In patients suffering from any 
form of neuralgia who are also migrainous these remedies appear to act 
remarkably well. The writer's usual formula is the following ; it is 
especially valuable in visceral neuralgia : 

R. — Dimethyloxychinolin gij. 

Ext. erythrox. fid. . ^ij. 

Codeinse . gr. vj. 

Glycerini et aquse ad ^ iv. — M. 

S. — A small teaspoonful to be taken in a wineglassful of water after meals 
four times a day. 

Salol and phenacetin maybe given in 10 grain doses every four, six, 
or eight hours. 

Exalgine, the newest of the analgesics, has been used by Fraser 
with success in various forms of neuralgia. The writer has used it in 
several cases of neuralgia in various regions, and though further trials 
of the drug are necessary before any very decided judgment can be 
formed, it appears to give relief without very materially diminish- 
ing the tendency to future severe paroxysms. This may not be the 
result when larger doses are administered. The writer did not exceed 
1 grain every three or four hours, dissolved in a tables poonful of water. 

Cannabis indica has been much employed in neuralgia. It does 
not appear to possess properties differing much from opium or mor- 
phine, but it is a valuable drug when for any reasons these are contra- 
indicated. It is more efficacious in neuralgias of the pelvic organs and 
in neuralgia occurring in migrainous subjects. One-half to I grain of 
the extract may be given in pill every four or six hours. 

Gelsemium is one of the best remedies which we possess when the 
affection is confined to the dental branches of the fifth nerve. It 
appears also to act more powerfully when the lower jaw or alveolar 
processes are the seat of the trouble. It affords relief in some cases, 



526 NEUKALG-IA. 

even when the teeth are carious and when the pain is arising from 
them. In one sad case which fell into the writer's hands after every 
tooth in the upper and lower jaws upou one side had been fruitlessly 
extracted from time to time during years of agony, gelsemium gave 
the first relief which the patient had enjoyed for nearly half his life- 
time. 

It must be given in doses bordering upon the dangerous in some 
cases, and the writer found a patient holding on to a lamp-post in the 
street unable to articulate and suffering from ptosis and diplopia, after 
taking two doses of 1^ grains each of the B. P. alcoholic extract which 
had been ordered for neuralgia of the fifth nerve. The B. P. dose of 
2 grains is dangerous. There is much difference in the susceptibility 
of different patients, and, as a rule, it is well not to exceed the dose of 
1 grain of the extract or 20 minims of the U. S. P. tincture until the 
patient has taken the drug for some time. These doses may be 
repeated at intervals of two hours until a painful feeling is experienced 
in the brows and eyeballs, followed by giddiness and some ptosis. As 
a rule, it is not safe to push the drug after ptosis has been noticed, or 
when the patient complains of double sight, or when the least stagger- 
ing of his gait has been observed. The mental faculties not being in 
the least affected by poisonous doses, the physician should not be mis- 
led by the clear and rational demeanor of the patient. Ringer has 
given drachm doses of the tincture every hour for six doses, with 
slight disturbance. 

Chloral has been recommended, but it almost always fails in 
neuralgia. It is of some use, however, when applied locally, as will 
be mentioned further on. Success occasionally has been achieved by 
administering a combination of chloral and morphine ; but such a 
combination is likely to succeed only in cases which probably would 
yield to safer drugs, and this combination is believed to be a dangerous 
one by several physicians. 

Croton-chloral or butyl-chloral hydrate is a remedy of the 
greatest value for neuralgia of the fifth nerve. Ringer states that for 
facial neuralgia it is the most efficacious remedy which we possess. 
He uses it in the neuralgic pains arising from carious teeth, in the 
obstinate and severe facial attacks in old people, in neuralgia of the 
back of the head, occiput, and neck, and in migrainous shooting pains 
extending from these regions toward the shoulders. The writer has 
been generally disappointed in the use of this remedy, except when 
administered for pure neuralgia of the fifth nerve, when it very often 
succeeded in relieving pain and afterward inducing sleep. For visceral 
neuralgia it appears to be useless. Ten grains may be given, and 5 
grains repeated every two hours for three or four times. The pilular 
form is the best, and gelsemium may be combined with it either in the 
form of extract, J grain, or of gelsemia, -^-q grain. This latter is 
Ringer's favorite method. He gives a pill containing -%fo grain ot 
gelsemia and 3 grains of croton-chloral every quarter of an hour for 



NEURALGIA. 527 

six or eight doses, then hourly. The writer has never had the courage 
to employ these drugs in such liberal doses. Liebreich has, however, 
recommended the croton-chloral as a harmless soporific, suitable even 
in heart disease, in doses of 60 grains. 

It may be administered with advantage in combination with Indian 
hemp, thus : 

H . — Butyl-chloral hydratis . . • . . . gr. v. 

Ext. cannabis indicae gr. £. — M. 

Make twenty-four such pills. 

S. — One pill to be taken every three hours. 

Atropine and belladonna, though more frequently used locally, 
are, nevertheless, of use often in neuralgia. The writer has found 
them much more valuable in abdominal or pelvic than in facial cases. 
In sciatica he has occasionally seen atropine succeed when given hypo- 
dermically in combination with morphine, when this drug had pre- 
viously failed without the atropine ; and, since it diminishes the 
dangers which sometimes follow upon the injection of morphine, it is 
a wise rule always to combine 1 or 2 minims of the 1 in 100 solution 
with every hypodermic dose of morphine. Trousseau's plan of treat- 
ing neuralgia consisted in administering A- grain of extract of belladonna 
every hour until giddiness was produced, when he lessened the dose 
and prolonged the intervals for several days. 

Belladonna may be given in the pilular form combined with most 
of the drugs already mentioned. The following is a valuable combina- 
tion for visceral neuralgia : 



R. — Ext. belladonna? 
Ferri arseniatis 
Codeinse . 
Acetanilidi 
S. — One pill to be taken thr 



gr- h 

gr- t\ 
gr- h 
gr. iij 



ss. 



-M. 



ee times a day after food. 



Hyoscyamus, stramonium, and hyoscine act in the same way as 
belladonna. 

The following combination of these drugs may be tried : 

R. — Tinct. hyoscyami -\ 

Tinct. stramonii > aa giv. — M. 

Tinct. belladonnse J 
S. — Twenty-five drops to be taken in a tablespoonful of water three times a 
day after meals. 

Iron and aRSEXic have already been spoken of when detailing the 
treatment of the causes of neuralgia. They are often of great value in 
cases where no evidence of anaemia exists, and a severe case of neuralgia 



528 XEURALG-IA. 

will seldom come before the physician which will not require either or 
both of these remedies at some stage of its progress. It will be gener- 
ally necessary to saturate the system with them in slow or chronic 
cases, toward their termination, when the pain has been subdued with 
anodynes. 

Since most of the remedies already mentioned are only indicated 
while severe paroxysms of pain are present or threatening, it will follow 
that there are intervals more or less prolonged in which the adminis- 
tration of the remedy is suspended. In the majority of cases time 
should not be lost, and in these intervals iron preparations, or full 
doses of Fowler's solution, arseniate of iron in pills, or Fowler's solu- 
tion in combination with the tincture of chloride of iron, and quinine, 
should be steadily administered after each meal. In this way the 
return of the paroxysm is rendered less certain, and these drugs should 
be continued long after the pain has subsided. 

Phosphorus is a remedy wdiich in the affection under consideration 
appears to act pretty much like the drugs just mentioned. The indi- 
cation which is regarded as especially pointing to the administration 
of phosphorus is evidence of brain or nerve exhaustion resulting 
from excessive and prolonged mental work under high pressure ; 
and in uncomplicated neuralgias affecting any region of the body in 
elderly people, phosphorus in full doses (^ to -fa grain) four times a 
day, often works well. One-twelfth grain doses have been often given 
by some, but the writer has seen unpleasant symptoms follow doses of 
half this amount, and it is a drug whose action should be watched 
from time to time during treatment of a prolonged attack, as a rule, -^ 
grain may be given three or four times a day for several weeks or 
months without risk. It can be advantageously combined with strych- 
nine or mix vomica. 

Phosphide of zinc (^ grain) may be employed instead of the free 
element. 

The Hypophosphites, in the form of Fellow's syrup, are very valu- 
ble adjuncts to the treatment of neuralgia, though it is hardly necessary 
to say that as they contain no free phosphorus, their efficacy does not 
depend upon this substance ; and the same remark applies to phos- 
phoric acid, to the syrups of phosphate of iron, of Parrish, and of 
Easton. 

Zinc preparations are often of use in the treatment of the various 
neuralgias. The best of them is the valerianate, and it is especially 
indicated in hysterical cases and in examples of the disease where the 
head and face are affected, and where periodicity is more or less 
marked. Less than 5 to 8 grains in one dose need not be given. It 
may be administered in the form of pills containing 3 or 4 grains each, 
or it may be combined with as much quinine, and may be swallowed 
in moistened wafer-paper. Often the stomach rejects the dose, but the 
writer has seen it succeed in neuralgia which had proved rebellious to 
many other drugs. Other valerianates may be tried, and the quinine 



NEURALGIA. 529 

iron, and ammonium salts have each their advocates. Valerianic acid 
and valerian root also are occasionally found useful. 
The following pill is useful : 

H . — Quininse valerian. ^ 

Ferri valerian. [■ aa gr. jss. 

Zinci valerian. J 

Ext, gelsemii . . . ' . : . . . gr. £. — M. 
Make '24 of such pills. 
S. — One pill to be taken three times a day, after food. 

Caffeine, theine, guaranine, napelline, cocaine, conium, 
codeine, narceine, strychnine, ergotin, sumbul, must be in- 
cluded in the list of anti-neuralgic remedies. Their indications are, 
however, very unsatisfactory, and like many members of this class, 
they must be used more or less empirically when other drugs have 
failed. As a rule, these substances may be said to be more likely to 
succeed in visceral neuralgias than in affections of the nerves of the 
head, face, or extremities, except in the case of caffeine, which appears 
to relieve facial neuralgia when given in large doses, especially in mi- 
grainous subjects. A combination of codeine and strychnine is some- 
times very useful in visceral neuralgia ; it may be given in the following 
formula : 

R . — Ext. nucis vomicae • g r - i' 

Codeinae . . gr. -f. — M. 

Make 24 of these pills. 
S. — One pill to be taken four times a day. 

Saffeol and menthol have been given with success by Dana in 
neuralgia, in doses of 15 grains dissolved in alcohol, or in capsules. 

Nitrite of amyl, nitro-glycerin, and other nitrites afford the 
best chance of success in cardiac neuralgic conditions, and inhalations 
of the amyl nitrite sometimes cut short the paroxysms of neuralgia of 
the fifth nerve. 

Chloroform and ether may be used as inhalations to give speedy 
relief in desperate attacks of neuralgia in any nerve, but for obvious 
reasons such powerful and possibly dangerous methods of relieving 
pain must necessarily be very seldom resorted to. 

Alcohol in large doses is open to the same serious objections ; and 
though it is a drug of much value in intensifying the effects of other 
narcotics, the physician must be always upon his guard in employing 
it in affections liable to run a chronic course, as, like the establishment 
of the opium habit when morphine has been unwisely prescribed, the 
alcohol habit may be the terrible result of the physician's indiscretion 
in permitting the use of alcohol for the relief of pain. 

Iodides and salicylates have been already referred to when 
detailing the treatment of the probable causes of neuralgia. The 



530 NEUKALG-IA. 

iodide of potassium, however, often proves very useful in cases where 
there is no history or suspicion of a rheumatic element or of a syphilitic 
taint. To be of use, however, it should be given in full doses, and less 
than 5 grains, speedily increased to 10 or even 20 graiu, three times a 
day, seldom proves beneficial. It is very valuable in some rebellious 
forms of sciatica ; and generally speaking, its administration is most 
clearly indicated in those cases of neuralgia which are characterized 
by nocturnal exacerbations, though, as already mentioned, these need 
not necessarily be of specific origin. In neuralgia affecting the cardiac 
organ, and in the neuralgic pains apparently arising from the nerves 
which supply the long bones, the iodides are of great value. Iodoform 
is sometimes administered instead of the iodide of potassium, but it 
has failed in the writer's hands. 

Chlorate of potassium has been reported as successful in facial 
neuralgia, but the writer has never seen any benefit from it. 

Actjka or cimicifuga has been found to relieve neuralgia of the 
fifth nerve and of the ovarian nerves. It is sometimes very useful in 
neuralgic conditions associated with, muscular rheumatism, and it may 
sometimes be combined with much advantage with iodides. 

Bromides are of little use unless when given in combination with 
other agents. They may, however, be used freely in this way with 
advantage ; and for the insomnia attending some cases, full doses of 
the bromide of potassium, given at night, with opium and iodides, are 
productive of much benefit. Anstie spoke highly of the value of large 
doses of bromides in cases arising from sexual excitement. 

Tonga has been much praised as an anti-neuralgic remedy, and 
sometimes proves very efficacious in facial neuralgia. It is believed to 
be a mixture of the bark and leaves of various species of rhaphido- 
phorcB and premnos from Fiji. The dose of the liquid tonga is one 
drachm three times daily. Often it fails entirely. 

Pulsatilla, piscidia erythrina, bebeeru, chelidonium, apiol, 
chamomile, veratrine (internally), digitalis, and hosts of other 
vegetable products have been used from time to time, but as most of 
them are now seldom employed, space need not be taken up with a 
discussion of their very doubtful merits as anti-neuralgics. 

Local measures for the relief of neuralgia will be now briefly re- 
ferred to, though it must not be inferred that their employment is only 
to be undertaken after the failure of the previously-mentioned methods 
of internal treatment. In some cases purely local treatment may 
succeed, but, as a rule, it should be employed at the same time, and as 
auxiliary to the internal administration of some of the remedial agents 
already detailed. 

Acupuncture has many advocates, perhaps chiefly among sur- 
geons, and the writer, though he never employs this remedy alone, has 
seen very decided benefits follow its use in the hands of others. It is 
indicated in sciatica, and occasionally its effects prove as rapid in acute 
cases as they do in lumbago, but like almost every other remedy used 



NEURALGIA. 531 

in neuralgia, acupuncture fails utterly in many cases. A stout nee- 
dle should be driven deeply into the tissues in several places over the 
course of the affected nerve, which should be punctured at each inser- 
tion. There does not appear to be any advantage in allowing the 
needle to remain in situ for any length of time. Acupuncture of cor- 
responding painful spots upon the opposite side of the body has been 
reported as successful. 

The writer's method of combining acupuncture with the hypoder- 
mic injection of a weak solution of morphine into the affected nerve, has 
been already referred to upon page 523, and he may here repeat that 
he believes it to be the most efficacious combination of local and con- 
stitutional methods at the disposal of the physician in dealing with 
obstinate neuralgias. He generally combines with the dose of mor- 
phine -^q grain of atropine. 

Aquapuxcture, or the deep injection of a small quantity of pure 
water into the nerve or its immediate neighborhood, has also given 
good results. 

Osmic acid has been strongly recommended as an injection in 
sciatica, and the writer has employed it very many times in obstinate 
cases with success. Billroth has found it to cure sciatica which had 
resisted all treatment for years ; he injected it deeply between the 
ischium and trochanter. The writer takes 15 minims of a freshly - 
prepared 1 per cent, solution of the acid, and dilutes this quantity 
with the full of a large hypodermic syringe of distilled water ; he in- 
jects this deeply into the nerve, in half to one dozen places, from the 
ilium to the heel, introducing 1 or 2 minims with each insertion of the 
needle. 

Of course, the nerve trunk and its branches are often missed, the 
needle passing right through them or falling short of them in some 
cases, but the physician should aim at lodging the injection in the 
nerve substance. It is evident that the success of this vigorous treat- 
ment may be altogether owing to the numerous acupunctures inde- 
pendent of any virtue possessed by the osmic acid. In using the 
hypodermic needle for acupuncture it is necessary to be careful lest it 
should break, as considerable force is generally needed in piercing the 
skin and deep tissues. There is no danger of such an accident if a 
short grip of the needle be taken by grasping it firmly between the 
finger and thumb, at a distance from the point supposed to correspond 
to about the probable depth of the sciatic nerve from the surface. It 
should be plunged in boldly, and if a little carbolic acid be previously 
painted over an area as large as a sixpence where the puncture is to 
be made, little pain will be felt. 

Cocaine may be employed in exactly the same way, and i grain 
may be injected in one or two places, though very much greater quan- 
tities have been injected without producing unpleasant results. 

Antipyrine and other substances, such as carbolic acid, turpentine, 



532 NEURALGIA. 

creasote, oils of peppermint and cloves, may be injected, but, as a rule, 
they produce great pain, and may possibly lead to sloughing. 

Chloroform, injected in doses of 5 to 10 minims, has given excel- 
lent results in the hands of Bartholow. 

Counter-irritation is a long-established method of treating the 
various forms of neuralgia, and the different ways in which it may be 
employed are almost endless, when we consider that nearly every sub- 
stance capable of irritating or blistering the skin has been at some time 
or other advocated as a specific for neuralgia. Cantharides, either in 
the form of blistering collodion or as small circular of narrow strips of 
blistering paper may be used. The latter are certainly to be preferred, 
as they can be removed after a few hours' application in those cases 
where an effect short of real vesication is desired. They can be placed 
over the trunk or principal branch of the affected nerve. Thus, in 
sciatica, a blister 1? inches broad by 3 long may be applied over the 
nerve as it emerges from the pelvis. In two hours the blister may be 
removed and placed over the upper part of the popliteal, where it may 
be suffered to remain for three or four hours. 

Anstie laid down the rule that the blister should be applied over the 
posterior branch of the same spinal nerve trunk as that from which 
the neuralgic nerve springs. 

In neuralgia of the face or scalp, relief may be obtained by applying 
a small circular blister over the temple or behind the ear and allowing 
it to remain on until complete vesication occurs. 

The actual eatery is still by some preferred to blistering. Valleix, 
after etherization, passed it lightly along the course of the affected 
nerve so as to produce superficial eschars. Many cases yield to this 
treatment after resisting every other. Corrigan's iron may be used, 
after heating to a dull heat with the spirit lamp or it may be dipped 
in boiling water and pressed upon the part. By graduating the degree 
of temperature almost any effect from the mildest counter-irritation to 
the rapid destruction of the superficial tissues, may be produced. The 
thermo-cautery can also be used. Mustard poultices are highly rec- 
ommended as a means of counter- irritating in neuralgia, though the 
writer has always chanced to see aggravation of the symptom produced 
by them. 

Capsicum, in the form of the Chili paste, may be used with advan- 
tage in the very chronic cases. 

The plan of causing rapid vesication by the application of strong 
solution of ammonia, and sprinkling morphine, strychnine, or other 
drugs over the excoriated surface, is now seldom employed. 

Of local anodynes there are many which have proved useful. Thus — 

Menthol, rubbed along the course of superficial neuralgic nerves, 
often affords speedy relief. The liniments of belladonna and aconite 
may be used in the same way, and chloroform may be combined with 
them. The writer has employed the following to paint over the skin 
covering superficial painful nerves, chiefly about the face and neck : 



NEURALGIA. 533 

\l— Olei caryophylli ^iv. 

Olei menthse pip 3 iv. 

Chloroformi purif. gij. 

Tinct. aconiti sjvj. — M. 

S. — To be used as directed. 

Its application is often followed rapidly by marked relief, though, 
like most other anti-neuralgic remedies, it sometimes produces no effect 
at all. 

Atropine, aconitine, and veratrine ointments are powerful 
local anodynes, and should be gently rubbed into the skin over the 
course of the affected nerves until numbness and tingling are experi- 
enced. 

Intercostal neuralgia is said to yield sooner to the belladonna than 
to the aconite alkaloid. 

Chloroform, ether, compressed carbonic- acid gas, and 
methyl chloride have been often found very efficacious in giving 
speedy relief to acute, agonizing pain. Freezing of the part is not 
necessary to produce the best results, and sometimes it should be 
avoided. In the use of the methyl chloride a few seconds' application 
to any one spot is generally long enough, as severe irritation, and even 
sloughing, may follow its use. 

Iodoform, in saturated solution in chloroform, amyl, colloid, 

ICHTHYOL, HYDROCYANIC ACID, OLEATE OF MORPHINE, equal parts of 

chloral and camphor, are among the many local anodynes vaunted 
as specifics for neuralgia. With none of this batch has the writer any 
experience. 

Sulphur externally sometimes gives excellent results. It should 
be freely sprinkled over the neuralgic region on cotton wool, and then 
bandaged firmly. In sciatica, the writer has had great satisfaction in 
many chronic cases with this remedy. 

The spinal ice bag and the ice cap have been tried, but they very 
often greatly aggravate the paroxysm. The wet pack and other hydro- 
pathic methods may be safely tried in many cases of obstinate 
neuralgia. 

Electricity, though only mentioned at the end of the list of reme- 
dial agents, is one of the most valuable methods which we possess for 
treating the various forms of neuralgia, but, like every other remedy 
mentioned, it often fails, and at present there is no known method by 
which we can venture to prophesy its success or failure until the ex- 
periment has been carried out. It is about equally valuable and 
equally worthless in visceral, facial, or sciatic neuralgia, and, until 
tried, the relative value of each form of electrical treatment cannot 
be determined. 

As a rule, it does not practically matter about the exact position of 
the electrodes, though the rule is laid down that to produce the most 
marked sedative effects the circuit should be closed with the anode 



534 NEURALGIA. 

over the affected nerve, and the kathode upon an indifferent region in 
the neighborhood. The continuous current is the most likely to give 
the best results. The electrodes should consist of large flat metallic 
plates covered over with several layers of warm moistened wash leather 
or sponge. One being placed over the trunk of the nerve, the other 
may be slowly moved up and down over the regions to which its 
branches are supplied. Ten, fifteen, or twenty Leclanche cells may be 
employed. No shock or painful contraction of the muscles should be 
produced, and the application should be continued for five or ten min- 
utes. The writer has observed neuralgia to disappear after a few such 
applications, though this is a comparatively rare occurrence. 

In sciatica, the current from fifteen to twenty cells may be made to 
traverse the lower extremity, and before lifting the electrode off the 
skin the various cells may be gradually cut off by using the handle 
of the switchboard so as to prevent a shock. 

Where the continuous fails, the interrupted current may be em- 
ployed. It is not advisable to use many cells, and the interruptions 
should be rapid. When this fails, a strong current may be used as a 
counter-irritant. The writer has several times found patients who 
have used the common electro- magnetic machine with great benefit 
even in sciatica. 

McClure- speaks highly of static electricity, and he has made the 
important observation that during its use the action of internal reme- 
dies appears to be much intensified. In facial neuralgia he employs 
the souffle by a metallic point for ten minutes, and where this fails, he 
draws fine sparks by approaching it nearer to the skin, and finally he 
extracts heavy sparks by means of the metal ball, and he finds that 
occipital, facial, cervical, and brachial neuralgias readily yield to this 
treatment. 

Pressure upon the nerve trunk, and the application of a succession 
of smart taps or vibrations generated by means of an ingenious appa- 
ratus devised for the purpose, have been followed by results which, as 
a rule, can be more readily obtained by other remedies. 

When a case of neuralgia has proved rebellious to the various reme- 
dial agents already enumerated, the question of surgical interference 
must be seriously considered. Before finally deciding it will be worth 
while to try massage and a change of climate, when the patient's 
means and the nature of his neuralgia will admit of such a step. A 
dry, warm atmosphere may be tried. A long sea voyage often gives 
excellent results, and does away with the necessity of surgical operations. 

The following are the various procedures which have been success- 
fully practised for the relief of obstinate neuralgia : 

1. Nerve stretching. 

2. Neurotomy, or section of the nerve. 

3. Neurectomy, or excision of a portion of the nerve. 

4. Nerve-avulsion, or the tearing out of a nerve trunk from the bony 

opening through which it passes. 

5. Nerve ligature. 



NEURALGIA. 535 

Nerve stretching is performed in two different ways. The first, or 
minor method, known also as bloodless nerve stretching, should always 
be tried before resorting to the cutting operation, when the anatomical 
position of the nerve permits. The bloodless method can be easily car- 
ried out in the case of the sciatic nerve. The patient being thoroughly 
brought under the influence of chloroform or ether, the hip-joint is 
powerfully flexed, after which the knee is forcibly extended, and then 
the ankle is brought into a condition of extreme flexion, and the entire 
limb should be maintained in this position for about fifteen minutes, 
when a vigorous massage may be applied for ten or fifteen minutes 
more. Sometimes the limb is bandaged in this position, but, as a rule, 
this is not advisable. The stretching may be repeated two or three 
times, the patient being kept quiet in bed in the intervals. The writer 
has seen an obstinate attack of sciatica speedily disappear in a patient 
who fell in such a position as to severely stretch the limb and nerve. 

In the more radical method of stretching a nerve, the operation is 
performed, under chloroform, by cutting down upon the trunk and 
exposing the nerve sheath, after which the forefinger or a blunt hook 
is passed underneath it, and steady traction made for about ten minutes, 
as the nerve is lifted from its bed and extended both in the proximal 
and distal directions. The wound is treated upon ordinary surgical 
principles, with stict antiseptic precautions, and rest of the limb upon 
a splint should be enforced for ten days at least, until healing is firmly 
established. The ultimate result is highly satisfactory, especially when 
it is remembered that only the most obstinate cases are submitted to 
this method of treatment. According to Marshall, three out of every 
four cases so treated are permanently cured. 

When stretching fails, a similar incision may be made in the direc- 
tion of the nerve trunk, the sheath exposed, and the nerve divided 
after pulling it gently out of its bed. 

In the more severe operation of neurectomy, undertaken after failure 
of the division of the nerve, a portion of the length of the nerve is 
completely removed. 

In avulsion, after anaesthesia has been fully established, a free incision 
is to be made over the nerve near to its emergence from the bony canal 
or foramen through which it passes, and after its trunk has been fully 
exposed and freed from surrounding attachments as far as possible, it 
is seized between the blades of a stout pair of forceps, and forcibly torn 
out of its bony canal. Sometimes it may be even necessary to gouge 
out the bone surrounding the foramen in order to tear away as much 
of the nerve as possible lying in the canal. 

Ross, after stretching the inferior dental nerve, was compelled at a 
subsequent period to excise half an inch of it, and upon a second return 
of the neuralgia he repeated the operation, at the same time excising a 
portion of the lingual, and upon a continuance of the neuralgia, he 
removed the entire Gasserian ganglion and the superior maxilla. 4 {jj(] 

The method of treating neuralgia by hypnotic suggestion is men- 



536 NEURITIS. 

tioned last. The writer has had no experience whatever of its working, 
but from the reports of those who have been laboring specially in this 
rather mysterious field of therapeutics, most brilliant reports continue 
to flow in. After hypnotization, caused by fixing the eyes upon a 
bright object for a brief period, the patient is assured that all pain will 
disappear immediately, and upon awakening this result is, according 
to reports, almost always found. Even in cases where neuralgia has 
been caused by some organic mischief producing pressure upon the 
nerve trunk, the pain has been found to keep away for very long 
periods. 

The treatment of the various forms of neuralgia — i. e., of neuralgia 
affecting the different nerves of the body — need not be gone over in 
detail, as the same principles are, for the most part, applicable to all 
nerves. Sciatica will be again briefly referred to under its own heading. 

NEURASTHENIA— See Hysteria. 

NEURITIS. 

The first step toward treatment is to remove the cause. Thus, if 
owing to syphilis or rheumatism, these diseases must be met by appro- 
priate remedies. Iodide of potassium, or mercury, or both combined, 
being indicated where there is any reason to suspect syphilis, and salol, 
salicylates, and at a later stage iodides, if there be any evidence of 
rheumatic inflammation, gout, and diphtheria. Tumors or foreign 
bodies, or inflammatory processes leading to purulent collections press- 
ing upon and irritating the nerve in some part of its course, call for 
prompt and radical treatment. Where neuritis follows exposure to 
the fumes or fine particles of irritant or other poisons, as mercury 
inhaled for long periods, or the dust of arsenical wall papers, or lead 
poisoning, or chronic alcoholism, removal of the cause or removal of 
the patient from the sphere of its influence should be determined upon. 
Cold and damp may be the exciting cause. 

Absolute rest of the affected limb, with anodyne applications or deep 
injections of small doses of cocaine or morphine, and the general treat- 
ment applicable to the early stages of acute neuralgia, are indicated. 
Leeching is of little use ; but a few small cupping glasses placed over 
the leech bites may be productive of relief, and may have the power of 
controlling the inflammatory action going on in the sheath of the 
nerve. Blisters may be tried. Paralysis and wasting of muscles must 
be met at a later stage by the constant use of a weak, continuous, and 
afterward of an interrupted current and massage. In the multiple 
variety local applications are of little use. The internal administra- 
tion of large doses of iodide of potassium, with occasional resort to 
antipyrine for the relief of pain, is the best treatment. 

Where much pain and hyperesthesia exist, the affected parts may be 
swathed in absorbent cotton wool, and bandaged so as to prevent 



NEUROMA — NIGHTMARE. 537 

variations of temperature. A water bed in which the fluid can be kept 
at an even and uniform temperature is a valuable adjunct to treatment. 

NEUROMA. 

Though much temporary relief may be obtained by the judicious use 
of pain-relieving remedies, as detailed under the local treatment of 
neuralgia, permanent benefit must only be expected from cutting down 
upon the tumor and dissecting it out. Where it is found to involve 
the entire thickness of the nerve trunk, this should first be well 
stretched before excising the diseased portion, in order that the cut 
ends may be brought together by sutures before closing up the wound. 

Mayo Robson, after excising a considerable length of the median 
nerve, which was involved in a tumor to which it was adherent, trans- 
planted a piece taken from the posterior tibial nerve, dissected out of a 
limb which had been amputated immediately before the neurectomy 
operation. The graft was retained in position by catgut sutures passed 
through its extremities. At the end of five weeks sensation in the 
parts below the operation was perfectly restored, though some atrophy 
of the muscles supplying the thumb remained. Notwithstanding that 
there is room for questioning this result as being one of genuine nerve- 
grafting, it clearly points to the treatment which should be adopted 
(when possible) after the removal of a large piece of a nerve in its 
entire thickness in the operation for a neuroma. 

NIGHTMARE. 

The treatment, if possible, should be preventive, and a close 
scrutiny of the causes which were at work in former attacks will- 
generally give the clue to the management of the patient's feeding, 
sleeping, or mental work, which will prevent the recurrence of the 
disorder. As a rule, it is produced by the presence of a considerable 
amount of undigested or indigestible food lying in the stomach, and 
this is very often produced by late suppers in those who dine early. 
The habit of occupying the mind by severe exercise up to the moment 
of lying down may be the cause of the attack. Severe business 
worry, prolonged grief or anxiety, and alcoholic excesses may be the 
cause. Some patients are liable to experience attacks when they turn 
over upon their back to sleep, or when the weight of the body, sinking 
gradually into the depths of a soft feather bed, causes the head to 
slip off the pillow. Late dinners which do away with the necessity of 
supper, a hard hair mattress, and a contrivance which awakes the 
patient the instant that he turns over upon his back, such as the tying 
of an empty cotton-reel across the back (i. e., over the spine), and the 
avoidance of indulging in severe mental labor before retiring to bed, 
will generally prevent the attack. A full dose of bromide of potas- 
sium or, better still, sulphonal will be worth trying when there are 
special reasons for suspecting an attack. 

35 



538 NIGHT TERRORS. 

When the attack comes on, the sooner the patient gets roused 
thoroughly the better. There is not much use in prescribing reme- 
dies which he is to use himself, as by the time he would be hi a posi- 
tion to employ them the attack would have entirely passed away. He 
should be advised to get rapidly out of bed as soon as he is able, and 
dash some cold water upon his face, or dip his head into a basin of 
water. When the attack tends to recur upon the patient's again lying 
down, he may induce vomiting, and insure the complete evacuation of 
the contents of the stomach. The friends of a patient who is subject 
to attacks of nightmare may be instructed to administer a whiff of 
nitrite of amyl, strong ammonia, or a cold douche. 

NIGHT SWEATS— See under Phthisis. 
NIGHT TERRORS. 

The distressing attacks occurring in young children, and known as 
Pavor noctumus, appear to closely resemble nightmare in the adult. 
Their cause is often obscure. Sometimes they are associated with 
delayed dentition, worms, and indigestion, but often appear to come 
on in otherwise healthy children, whose active little brains lead them 
into vivid dreaming. Where a cause can be determined, of course its 
speedy removal is the first duty of the physician, who should minutely 
examine into the patient's condition, especially with regard to the 
existence of epilepsy, and every departure from health should be 
remedied. The moral surroundings of children so affected should be 
closely studied. The ghost stories and appalling tales of the nursery, 
often combined with threats of boiling evil and future punishment, 
should be discountenanced. 

f Dyspepsia should be met by a powder after each meal, containing 
a few grains of bicarbonate of soda and a small dose of powdered 
rhubarb. 

Smith lays stress upon the importance of forbidding potatoes, pud- 
dings, fruit, and cake. 

After correcting every probable or possible cause, the physician 
may think of administering drugs, with the view of preventing future 
attacks. 

Bromides of potassium, sodium, and ammonium afford the best 
means of accomplishing this. One good dose, according to the age of 
the child, may be given at bed-time. Sulphonal or chloral may be also 
given. The latter drug is, however, not so suitable, as patients often 
dream unpleasantly under its influence. For this reason opium is also 
unsuitable. 

If seen during the attack, little can be done save by soothing the 
patient's excitement and calming his fears, by assuring him of his 
present safety, though often this will be of little use, as there appear 
to be delusions and hallucinations which will not quite leave the 
patient until after he falls asleep again. Punishment, cold douches, or 



539 

any treatment which could possibly add to the little patient's distress 
is to be strongly condemned. 

The following mixture may be administered at bed-time every night 
to a child one year old : 

R. — Ammonii bromidi \ _ . 

Sodii bromidi i • o • 

Vini antimonii . . . . . . . 3 ss. 

Syr. simpl. 3j. 

Aquse menth. pip. ad ^ij. — M. 

S. — A teaspoonful to be taken every night at bed-hour. 

Money recommends a mixture like the following for excitable or 
nervous children. It may be given to a child seven years old : 



R . — Ammonii bromidi 
Pulv. rhei 
Sodii bicarb. 
Syr. zingiberis 
Aquse menth. pip. 



• 3j. 

gr. xlv. 

. 3jss. 

ad ^ iv. — M. 



S. — Take two teaspoonfuls three times a day, after meals. Shake the bottle. 

NIPPLES, Sore. 

Much of the miseries attending first confinements may be attributed 
to trouble starting in the nipple during pregnancy. This may often be 
prevented by early attention and absolute cleanliness, as the thick 
epithelial crusts should be regularly washed away, so as to cause the 
epithelial covering of the nipple to attain a sufficiently robust growth, 
otherwise it remains delicate and liable to tear, fissure, or ulcerate. 
Mischief is done by the application of strong astringent applications at 
this stage. Such measures, by hardening or partially tanning the 
skin, cause it to crack when traction is afterward made upon it. The 
most that should be done in this way is occasional sponging with weak 
spirit lotion. Continual moist applications produce a sodden condition, 
in which linear ulceration is apt to be set up. Glycerin, vaseline, or 
ointments are also objectionoble. When tenderness is felt in the nipples 
during pregnancy, they should be protected from the friction and pres- 
sure of the dress by the constant use of a proper vulcanite or soft 
metal nipple shield. 

Depression of the nipple, in which it lies in a hollow, projecting 
above the surrounding skin so slightly as to render it impossible for 
the child to grasp it, is a common condition, and if discovered suffi- 
ciently early may to a great extent be remedied by wearing all through 
the later months of pregnancy a properly-fitting shield, made of soft 
metal. This shield should be of the form and proportions of a large 
nipple, with a wide base to rest upon the areola. It is known as the 
Wansbrough metallic shield, and is of the greatest value in this and 



540 

many other conditions. Apparently some action is set up between the 
skin and the metal; which becomes moistened with perspiration, and 
in the case of ulceration this has sometimes a very beneficial effect 
upon healing. For our present purpose it is only the mechanical 
effect of the nipple being driven slightly into the hollow cone of the 
shield by the pressure of the dress that is desired, so as to counteract 
depression. India-rubber shields are also useful. Where this plan 
fails, there is little use in drawing out the nipples by means of any of 
the innumerable suction toys designed for this purpose ; they often do 
mischief. 

Kehrer has devised a simple operation, by which the depressed 
nipple is raised out of the hollow, saucer-shaped depression in which 
it lies. He excises a ring, or two crescentic pieces of skin surround- 
ing the nipple. As the wound heals, the approximation of its lips 
pulls upon the skin immediately surrounding the nipple, and causes it 
to project. 

Trouble being anticipated owing to the faulty formation or tender- 
ness of the nipples, extra care should be taken immediately after 
delivery, as fissures in this locality are the chief cause of suppuration 
of the mammary gland. Two extremes must be guarded against — 
the child should not be permitted to tug away for any length of time 
at the empty breasts before milk has come to them, nor should it be 
kept from the nipple until the gland has become so engorged with milk 
that emptying of it is rendered most difficult and painful. 

If, notwithstanding these precautions, the nipples become tender 
and painful, a glass nipple shield, to which an India-rubber teat is 
directly fitted on, may be applied to the tender nipple. Through the 
teat the child may be able to empty the breast without causing much 
pain to the mother. 

This often proves unsatisfactory, and cause even more pain than the 
lips of the child directly applied to the nipple, and the physician has 
his patience sorely taxed by trying one form of breast-exhauster, 
nipple shield, and suction apparatus after another. In the meantime 
the soreness of the nipple increases, and is found to be caused by an 
ulcer, fissure, crack, or abrasion w r hich demands local treatment. 

The best lotion for general use is the following. The writer finds 
it much more likely to be successful in causing rapi.1 healing than any 
other : 

R . — Alcoholis purif. ^j. 

Aqme rosse ^iij. — M. 

S. — To be used as directed. 

This should be sponged freely over the nipple and areola after each 
occasion when the child attempts to drink, and a small circular piece 
of lint soaked in it should be laid upon the excoriated surface, and 
covered carefully over with a larger piece of oiled silk. 



NIPPLES, SORE. 541 

Some authorities recommend that the fissure or ulcer should be 
touched with a finely-pointed pencil of nitrate of silver. This is often 
a very painful practice, and the writer thinks that he has seen it deter- 
mine suppuration. He has obtained more satisfactory results by touch- 
ing the dried surface of the excoriation with strong liquefied carbolic 
acid before applying the above lotion. Carbolic lotion (1 : 30) makes 
an excellent application, and sometimes eases the pain of the fissure by 
acting as a local anaesthetic, though the writer believes that healing is 
more rapid under the spirit and rose water. 

Nearly every known form of astringent application has been recom- 
mended and used for the healing of sore nipples, and each nurse and 
physician believes in some one formula. As a rule, it may be said 
that all ointments and greasy applications are found by experience to 
be much less satisfactory than lotions. 

Astringents are open to the objection that by hardening the tissues 
they sometimes appear to increase the tendency to cracking and Assur- 
ing. The best pure astringent application is an infusion of green tea. 
If used at the proper time it often gives excellent results. 

Glycerin of tannin (1 : 4) is a convenient and valuable remedy, 
and is not open to the imputation of markedly increasing the tendency 
to crack or fissure. 

Tannin may also be applied in watery or spirituous solutions. 
Catechu, rhatany, kino, and other vegetable astringents have been 
used. 

Various iron and lead salts are also much praised. 
Substances in the form of fine powder may be used with advantage 
in the early stages, and when there is any tendency to eczema, they 
are very soothing. In this way, with a puff, zinc oxide, Fuller's 
earth, powdered starch, etc., may be applied. Glycerin of starch has 
similar action. Lime-water, balsams of Peru and toiu, chlorate of 
potash, Friar's balsam, collodion, weak sublimate solutions, and many 
other plans may be mentioned. 

The glycerin of borax (1 : 5) must not be omitted. The writer 
has often treated cases all through the different stages with this 
remedy alone with much satisfaction. Where for any reason the spirit 
and rose water lotion should not be used, this is the application which 
he would select for routine treatment. 

During the healing of the excoriations the best must be done to give 
the nipple rest by the use of pumps and shields, one after another of 
which should be tried until the least painful method of emptying the 
breast is arrived at. In very severe case suckling must be suspended 
for a time, or even permanently, and in any case the supply of milk 
should be diminished, if abundant, by the judicious use of purgatives 
and alterations in the diet of the patient. The child's mouth should 
be kept healthy by constant cleanliness, and the occasional application 
of the glycerin of borax to the tongue and lips. (See also under Mam- 
mary Gland, Inflammation of, page 482.) 



542 NYMPHOMANIA. 

NIPPLE, Malignant Disease of, 

Can only be met by removal of the gland in young or middle-aged 
subjects. In aged patients the nipple may be removed with the sur- 
rounding tissue, but this is not an operation likely to be followed by 
satisfactory results. The writer has under observation a typical case 
of carcinoma, following eczema of the nipple (Sir James Paget's nip- 
ple), and the progress is so very slow, extending over many years, 
that operative interference does not appear to be warranted. 

Eczema of the nipple occurs as in other regions, and proves often 
susceptible to ordinary treatment, such as astringent lotions, the best 
of which would be strong solution of subacetate of lead 1, liquor 
carbonis deterg. 1, water 20. Ointments are more convenient, the 
most useful combination being zinc oinment 7, liquor carbonis deterg. 
1, ammoniated mercury 3. Powders, such as oxide of zinc, Fuller's 
earth, or starch powder may be used with advantage. (See Eczema.) 

Of a different nature, however, is the inveterate chronic eczema first 
described by Paget, which, confining itself for many months or even 
years to the nipple and areola, gradually and almost imperceptibly 
passes into a truly malignant form of disease, invading the deeper 
portions of the gland. For the latter condition, as already mentioned, 
there is no remedy but removal of the entire breast, and even this is 
far from being followed generally by satisfactory results. For the 
preliminary eczematous stage, little can be done. Most authorities 
regard it as beyond the reach of medicine. Certainly, irritating or 
stimulating applications should be forbidden, as by such means there 
is reason to believe the ultimate development of carcinoma may be 
hastened. The nipple should be carefully shielded from friction and 
the irritation liable to be produced by the pressure of dress. A vul- 
canite or rubber shield answers this purpose well. Of local applica- 
tions the best will be simple vaseline, or a very weak spirit lotion, con- 
taining 1 grain of corrosive sublimate to every 4 ounces. The writer 
would advise the alternate use of these applications for about one 
month at a time. 

NOCTURNAL EMISSIONS— See under Spermatorrhoea, Hypo- 
chondriasis, and Masturbation. 

NODES— See under Syphilis. 

NOSE, Affections of— See Ozsena, Polypi, etc. 

NYMPHOMANIA. 

The treatment of this affection when fully established can only be 
carried out satisfactorily in institutions which possess all the machinery 
necessary for the management of cases of insanity. Seldom in pri- 
vate practice can the serious responsibility of undertaking the moral, 



OBESITY. 543 

hygienic, and medicinal treatment of such cases be safely risked by 
the physician. As the nature of the affection is one which tempts the 
relative of the patient to shun the exposure which they feel that re- 
moval to an asylum entails, the physician is often compelled to take 
charge of such cases for a time. 

It is needless to dwell upon the question of moral treatment. This 
must be left in the hands of discreet and trusted female relatives or 
nurses. One thorough examination of the sexual organs should be 
made where there are reasons for suspecting local mischief. Fre- 
quent vaginal examinations must be strongly condemned, but as there 
may be possibly some serious local complaint, it is advisable to have 
this set right when practicable. Ovarian neuralgia or inflammation, 
endometritis, congestion or chronic irritation of the external genital 
organs, may be the ' exciting cause of the mania. When such lesions 
are detected, and when from a serious consideration of the history and 
present condition of the patient, there appears to be a legitimate pros- 
pect of improvement after the local mischief has been removed, local 
treatment may have a fair trial. 

Drugs alone are of little value, but as adjuncts to moral and 
hygienic management, bromides, camphor, and other anaphrodisiacs 
may be administered in full doses. Enemata of tobacco have been 
recommended, but in doses short of danger they are useless, and hence 
cannot be judiciously employed at all. 

OBESITY. 

Many volumes have been written upon the treatment of this not 
uncommon condition, and a considerable number of " systems " or 
plans have been elaborated, some of which are based upon false 
physiology. It cannot be too strongly stated that too many deaths 
are indirectly owing to unwise attempts to rigidly carry out the details 
of these systems. The success of such attempts too often means that 
the patient is left in a much worse condition in other respects, though 
his weight may have been considerably reduced. 

As a rule, it may be said that the treatment of obesity by the ad- 
ministration of drugs should be left out of the question. Occasionally 
drugs may be used as adjuncts to other measures, but if used at all 
they must play a very subordinate part. If administered in such 
quantities as will ensure a marked reduction of body weight without 
the aid of radical changes in dietary, serious danger to life may result. 
The medicinal substances recommended for the treatment of obesity 
are — vinegar, alkalies, chloride of sodium, bromides of sodium and 
ammonium, salts of potassium as the permanganate and iodide, liquor 
potassse, vegetable acids alone or in combination with potassium or 
sodium, fucus vesiculosus. 

All of these, except perhaps fucus vesiculosus, are productive of 
serious mischief when given in doses sufficient to diminish the amount 



544 OBESITY. 

of fatty tissue, owing to their deleterious action upon the composition 
of the blood, when administered for long periods. Vinegar is 
often found to be the cause of serious mischief in vain females who 
imbibe it in large quantities with the intention of reducing their florid 
complexions and comely rotundities. 

Fucus vesiculosus, which is the basis of a popular remedy for obesity, 
is the ordinary bladder sea-weed or wrack. The writer has never had 
an opportunity of studying its action, but he knows that in some parts 
of the North of Ireland pigs have been fattened for market upon it, 
and it is therefore extremely improbable that in the ordinary doses 
recommended it can appreciably diminish the amount of fatty tissue 
in man, especially when we consider the close affinities existing be- 
tween the two, both structural, as observed in the dentition, and 
physiological, as seen in the omnivorous character of the food. 

Exercise is a powerful factor in the prevention of obesity, though 
not so reliable as a method for reducing it when once firmly estab- 
lished. No system of treatment will, however, be complete which does 
not recognize it as an important element, and little need be said here 
about it, since it will be referred to more fully in detailing Oertel's 
method. Exercise will, however, be of little avail in any case unless 
it be carried out in the open air. The writer believes that exercise 
systematically performed in the water or open sea, as in strong swim- 
ming, is a powerful means of safely reducing the body w T eight, and he 
has long recommended it when circumstances permitted obese patients 
to avail themselves of its benefits. 

The Turkish bath and the breathing of compressed air, with the 
view of increasing tissue waste, have not been followed by satisfactory 
results, within safe limits. 

From the above remarks it will be seen that the only satisfactory 
way in which obesity can be treated is by some dietetic system, of 
which there are many. Professor Yeo, in his invaluable work on 
Food in Health and Disease, has pointed out that almost all of 
these systems or dietetic methods aim at reducing the body weight by 
reducing the total quantity of the food consumed. The mistake made 
by those who devised the older plans of treatment was in considering 
that fat was only formed out of certain classes of food, while we now 
know that fat can be manufactured in the living laboratory out of — 
(1) nitrogenous bodies (albuminates), (2) hydrocarbons (fats), as well 
as from (3) carbohydrates (starch, sugar, etc.). The essence of the 
matter consists in the fact that some individuals manufacture and 
store up their fat chiefly from some one of these classes of food, while 
others may chiefly store up their fat from another class, and hence no 
one system can be expected to suit all the cases of obesity. By a care- 
ful study of each case the physician can soon find out which plan is 
best suited to it. Often the most suitable treatment will not lie in 
hard and fast adherence to any recognized plan, but in such modifica- 
tions of it as may be rationally decided upon after frequently weigh- 



OBESITY. 545 

ing the patient and watching which class of food best nourishes the 
body and maintains a high state of vigor without adding to the depo- 
sition of adipose tissue. Unless there are special reasons for the con- 
trary, it will be desirable to make the changes slowly and gradually at 
first. Sudden and marked reductions in the body weight cannot be 
safely made, and, moreover, the attempt often leads to the disarrange- 
ment of both appetite and digestion. 

The Banting method, originally prescribed by W. Harvey for Mr. 
Bantiug, is one of the oldest and best known plans for combating 
obesity. The following is a sketch of the dietary, which has been from 
time to time considerably modified to suit individual peculiarities : 

Breakfast (at 9 a.m.) : 5 to 6 ounces of animal food, consisting of 
beef, mutton, kidney, bacon, boiled fish, or hot or cold meat of any 
kind, except veal and pork. A little biscuit, or 1 ounce dry toast. A 
large cup of tea or coffee, without sugar and milk. 

This consists in all between solids and liquids of about 1 pound avoir- 
dupois. 

Dinner (at 2 p.m.) : 5 to 6 ounces of any fish, except salmon, eels, 
or herrings, or 5 to 6 ounces of any meat, except pork or veal, or 5 to 
6 ounces of any poultry or game. Any vegetables, except potatoes, 
parsnips, carrots, beet-root or turnips. One ounce dry toast. Cooked 
fruit out of a pudding and unsweetened. Ten ounces claret, sherry, or 
Madeira ; champagne, port, or beer, being forbidden. 

This consists in all between solids and liquids of about 1\ pounds. 
(In the original pamphlet there is some ambiguity about the poultry 
and game.) 

Tea (6 p.m.) : 2 to 3 ounces cooked fruit and a rusk or two, and 9 
ounces tea without milk or sugar. 

Supper (9 p.m.) : 3 to 4 ounces of fish or meat, as at dinner, with 7 
ounces claret, or sherry and water. 

It will be seen that starch and sugar are forbidden, and that the diet 
for the twenty-four hours consists of less than 1 pound — i. e., 13 to 16 
ounces — of animal food with 2 ounces bread, and less than J pound 
other solids, chiefly fresh vegetables and fruits, and about 2 pounds of 
fluids. 

This system is seldom employed now ; it is not capable of maintain- 
ing life for any considerable period without inducing dyspepsia and 
gout, and, it is stated, also renal disease. There is often loathing 
amounting to extreme or unconqerable abhorrence of animal food in- 
duced, and the patient complains of chilliness and weakness, and feels 
compelled to break through or throw up the system, with the feel- 
ing that life is not worth living under its restrictions. This plan, as 
modified by Vogel, is still occasionally employed. He permits boiled 
eggs, raw ham, thin bouillon, and some potatoes. 

Ebstein's system of reducing obesity is based upon a very different 
principle. He recognizes that Voit's conclusions are correct, and that 
fat is formed by albuminous foods, especially if carbohydrates are freely 



546 OBESITY. 

administered at the same time, and that this transformation takes place 
independent of the administration of fats. He insists that the presence 
of fats in the food tends to prevents its deposition in the body, and 
hence fatty substances, such as butter, very fat meats, and rich gravies 
enter into his method. These prevented the longing for hydrocarbons 
and produced a sense of satiation, and this is the chief feature in his 
plan of treatment. 

The following is a sketch of his dietary : 

Breakfast (6 to 7.30 a.m.) : 50 grammes (1.76 ounces) white bread 
(toasted) with plenty of butter, and 250 grammes (8.8 ounces), tea 
without sugar or milk, 

Dinner or luncheon (2 p.m.) : Fatty soup made from a beef-marrow 
bone; 120 to 180 grammes (4.25 to 5.6 ounces) fat meat with some 
cabbage, asparagus, spinach, peas or beans in moderate quantity, and 
2 or 3 glasses of light wine, and a little stewed fruit without sugar. 

Late in the afternoon : A cup of tea without milk or sugar. 

Supper (7.30 p.m.) : A large cnp of tea without sugar or milk ; 30 
grammes (nearly 1 ounce) each of bread and butter, one egg, or a cor- 
responding bulk of fat ham, fat roast meat or cheese, with fresh fruit. 
No alcohol. 

This spare diet has given moderately successful results. The amount 
of fat helps to reconcile the patient, where Banting's method could not 
be tolerated. The hydrocarbons are in too small amount to sustain 
life. 

In contrasting these two systems, the following figures from Professor 
Wood are of much service : 

Average food of a healthy man: Albuminous materials, 30 drachms ; 
fat, 25 drachms ; starchy hydrocarbons, 92 drachms. 

Banting's dietary: Albuminous materials, 43 drachms, fat, 2 
drachms ; starchy hydrocarbons, 5.25 drachms. 

Eb stein' s dietary : Albuminous materials, 25.5 drachms; fat, 21.25 
drachms starchy hydrocarbons, 11.75 drachms. 

If to these we add an estimate of the next method to be discussed — 
i. e. t Oertel's — their relative values may be seen at a glance. 

Oertel's dietary : Albuminous materials, 45 drachms ; fat, 9 drachms ; 
carbohydrates, 25 drachms. 

Oertel's system of treating obesity, improperly called also Schwenin- 
ger's, has already been detailed briefly when discussing the treatment 
of valvular lesions. Though introduced, in the first instance, to correct 
a condition of excessive corpulence, combined with great shortness of 
breath from fatty degeneration of the heart, it has been extended to 
the treatment of simple obesity and of valvular lesions. 

It differs, as will be seen from the above figures, from the Banting 
system by permitting more fat and hydrocarbons, and from Ebstein's 
by nearly doubling the albuminates and carbohydrates, and halving 
the fat. 



OBESITY. 547 

The chief feature in the method is the abstraction of water from the 
body. This is effected in reducing the supply to a minimum and in- 
creasing greatly its secretion and elimination by vigorous exercise, pro- 
ducing profuse sweating, and alse by the use of dry heat, as in the 
Turkish or hot air-bath. 

Upon page 343 will be found a diet table giving the particular com- 
position of the different articles and the amounts in English weights 
and measures. This is the diet table generally selected in the treat- 
ment of obesity associated with heart complications. It is, however, 
suitable in the management of simple obesity without any alteration 
worth mentioning, save that the roast meat in the last meal of the day 
may be omitted. The details of the climbing and other exercises have 
been before referred to. In simple obesity without cardiac complica- 
tions the amount of fluids may be gradually increased, and one or two 
glasses taken at the noon meal, and the amount of water increased 
from 2 to 10 ounces at the evening meal. 

Schweninger's modification of Oertel's method consists in the absence 
of any beverage at meals, all the fluid permitted being swallowed after 
the lapse of two hours after each meal. 

Germain See adopts Ebstein's method, only insisting upon copious 
imbibition of water or hot weak tea or coffee and abstinence from 
alcohol. 

Weir Mitchell recommends the simple plan of feeding upon skimmed 
milk, with several ingenious, restrictions. Thus he insists upon absolute 
rest in bed or upon a couch, and by careful weighings he determines 
the exact amount of milk necessary to sustain the body-weight, after 
which such a reduction is gradually made as will cause a loss of eight 
ounces in weight each day, or in weak patients four ounces daily ; 
massage twice daily, and latter on, exercise by means of the Swedish 
movements. Where appetite or digestion shows signs of rebelling 
against the milk, beef-tea, chicken or oyster soups, to relieve the 
monotony, may be permitted. When the requisite diminution in weight 
has been achieved active Swedish movements are still maintained, and 
the milk diet to a large extent kept up, and a rational diet selected to 
prevent increase in weight. This diet should include albuminates, fish, 
beef, mutton, and oysters, with but a moderate amount of hydrocar- 
bons ; ordinary exercise, and return to business may then be allowed. 

The Salisbury method, which consists in using a diet consisting of 
beef steaks and hot water, has been modified by Towers-Smith, so as 
to free it from some of the serious objections to which it formerly was 
open. 

The following is a sketch of his plan : He gives for the first fourteen 
days for breakfast and luncheon, one pound of lean rump steak ; for 
dinner, one pound of grilled cod and one pound of lean rump steak; 
and at intervals during the twenty-four hours, one gallon of hot water, 
and the last thing at night, half a wiheglassful of whiskey in cold water. 

During the next twenty-one days the diet is more varied, and the hot 



548 OBESITY. 

water is reduced to four pints. Mutton chops without fat, turbot, 
whiting, sole, green vegetables, and rusks are allowed. 

During the next thirty-one days the amount of hot water is further 
reduced to one quart, and tea is permitted with captain's biscuit, the 
bottom crust of a stale loaf, fish, fowl, game, joints of any kind, with a 
little light wine and Seltzer water ; 5 grains of bicarbonate of potassium 
are to be taken night and morning. After these periods, which amount 
to about nine weeks, the ordinary diet is indulged in. 

The period is so short that there is not time for the loathing of 
animal food to become established. If it does threaten, the beef may 
be prepared as beef-tea or essence. The writer would still strongly 
object to this method, even for so short a period as nine or ten weeks, 
unless some fresh vegetables were allowed. He has seen such deplor- 
able results where the plan was adopted, without the use of vegetables, 
for the cure of dyspepsia, that he believes it to be unwise to permit 
even this short period to be passed without fresh fruit and vegetables ; 
and as far as he can see there is no reason why green vegetables should 
be withheld in the treatment of simple obesity. 

This objection can be met in another way — i. e., by infusing a slice 
or two of a fresh lemon in each cupful of hot water. In this way no 
serious deterioration of the blood can take place, and the objectionable 
taste of the hot water is entirely removed. The large quantities of hot 
water consumed in this system are of great value in flushing out all 
the effete products, and without this element the eating of three or four 
pounds of lean meat daily might prove a serious risk to the integrity 
of the kidney. 

Schroth's cure for obesity is founded upon the opposite principle to 
the Towers-Smith or Salisbury method, as he excludes, as far as possi- 
ble, water or fluid in every form, hence this plan is often spoken of as 
the " Dry Cure." Dancel's method is almost identical with Schroth's. 
The diet consists chiefly of dry rolls, two or three days old, a little 
thick gruel, and a small amount of light wine. It is a method to which 
even the most resolute patients will not long submit. Moreover, where 
there is any gouty tendency along with the obesity, the dry cures, such 
as that just mentioned, and that of Schweninger's already described 
as a modification of Oertel's, are dangerous as routine remedies for 
obesity. 

Wood quotes the following dietary from an anonymous English mili- 
tary writer, who reduced his weight 117 pounds (more than one hun- 
dred weight in ten months by it : 

" 6 A. m. One pint of black coffee and one ounce of coarse brown 
bread or biscuit. 

" 9 a.m. Four ounces of lean meat, three ounces of brown bread or 
biscuit, and half a pint of coffee. 

"2 p.m. Six ounces of lean meat, three ounces of brown bread or 
biscuit, six ounces of green vegetables, and half a pint of any fluid 



OBESITY. 549 

except ale, effervescing wines, or aerated water, followed by half a pint 
of coffee. 

" 6 p. m. Half a pint of coffee. 

"9 p.m. — Two ounces of brown bread or biscuit and a couple of 
glasses of sherry or claret. 

"Fruit ad libitum and liquorice powder pro re nata" 

The different spare dietaries adopted at the various spas, such as 
Carlsbad, Kissingen, Ems, or Marienbad, are often very successful in 
mild cases. 

Yeo's method may be given in his own words : " The two principal 
objects of all these methods are, first, to make the corpulent person 
consume the excess of fat deposited in his body, by restricting the food- 
supply or augmenting its combustion by increased physical exercise or 
other means ; and, secondly, to establish a dietary which shall prevent 
its reaccumulation." 

Isone of the methods described are appropriate to the treatment of 
all cases of obesity indiscriminately, while any one of them may prove 
successful in suitable instances. 

In conclusion, the following is the method which we recommend to 
be generally adopted : A very careful examination should be made of 
each case, in order to ascertain the presence or absence of any organic 
disease, especially of any cardiac degeneration, and if we are satisfied 
that the obesity is not secondary to any other morbid state, or associated 
with any general degeneration of organs, we may proceed with confi- 
dence to prescribe an appropriate regime. 

The albuminates in the form of animal food should be strictly lim- 
ited. Farinaceous and all starchy foods should be reduced to a mini- 
mum. Sugar should be entirely prohibited. A moderate amount of 
fats, for the reasons given by Ebstein, should be allowed. 

Only a small quantity of fluid should be permitted, but enough 
should be allowed to aid in the solution and digestion of the food. 

Hot water or warm aromatic beverages may be taken freely between 
meals, or at the end of the digestive process, especially in gouty cases, 
on account of their eliminative action. 

No beer, porter, or sweet wines of any kind are to be taken, and no 
spirits, except in very small quantity. It should be generally recog- 
nized that the use of alcohol is one of the most common provocatives 
of obesity. 

A little hock, still Moselle, or light claret with some alkaline table- 
water, is all that should be allowed. The beneficial effect of such a 
diet will be aided by abundant exercise on foot and by the free use of 
saline purgatives, so that we may insure a complete daily unloading 
of the intestinal canal. 

Of animal foods all kinds of lean meat may be taken — poultry, game, 
fish (eels, salmon, mackerel are best avoided), eggs. 

Meat should not be taken more than once a day, and not more than 



55Q (ESOPHAGUS, FOREIGN" BODIES IN. 

6 ounces of cooked meat at a time. Two lightly-boiled or poached 
eggs may be taken at one or other meal, or a little grilled fish. 

^Bread should be toasted in thin slices and completely — not browned 
on the surface merely. Hard captain's biscuits may also be taken. 

Soups should be avoided, except a few tablespoonfuls of clear soup. 

Milk should be avoided, unless skimmed and taken as the chief 
article of diet. All milk and farinaceous puddings and pastry of all 
kinds are forbidden. 

Fresh vegetables and fruits are forbidden. 

It is important to bear in mind that the actual quantity of food per- 
mitted must have a due relation to the physical development of the 
individual, and that what would be adequate in one case might be alto- 
gether inadequate in the case of another person of larger physique." 

The writer has quoted these observations at length because they 
exactly embody his own views, and are opposed to the very question- 
able practice of accepting some one of the so-called " cures" and adher- 
ing to it in every case with slavish accuracy, often to the danger of 
the patient's life or health. The above plan can be fully carried out 
without preventing the patient attending to his business, it tends to 
produce no unhealthy craving, and it may be safely persisted in for 
long periods — three essential conditions insisted upon by Ebstein. 
Yeo makes the mistake, of forbidding fresh vegetables. 

CEDEMA— See under Bright's Disease, Heart Disease, etc. 
CESOPHAGTJS, Foreign Bodies in. 

Fish-bones and pins are perhaps the most frequently found impacted 
substances ; artificial teeth, coins, and morsels of bolted food are not 
rare. 

For small objects, as pins and fish-bones, the expanding horse-hair 
probang should be gently coaxed past the foreign body for several 
inches, when, by expanding the hair portion and keeping it open as it 
is being withdrawn, the bone or pin will be brought up by gentle 
manipulation. In the same way coins may be extracted by the money 
probang or coin catcher. In the absence of a suitable probang, a 
skein of thread attached to the end of a flexible bougie, as recom- 
mended by Davies Colley, makes a suitable substitute, in which the 
body may be entangled as it is withdrawn. 

Cregny advises in such cases that a skein of thread rolled up in a 
globular form, to which a piece of stout ligature silk is attached, should 
be swallowed in jam or butter, and after the foreign body has been 
passed the thread may be pulled up by dragging upon the silk. As 
it is withdrawn the foreign body may be found entangled in its meshes. 
Swallowing a large bolus of bread may carry small fish-bones and 
bristles before it into the stomach. Where the foreign body is soft it 
may be gently pushed down by the point of the probang or by the 
tube of the stomach-pump until it enters the stomach. Where angular 



(ESOPHAGUS, STRICTURE OF. 551 

hard bodies are impacted this is generally a dangerous practice, and a 
pair of long curved forceps should be employed. If high up in the 
oesophagus they may be seized by the surgeon's fingers. 

Occasionally the act of vomiting may be made to dislodge impac- 
tions. This may be induced by tickling the fauces or by giving apo- 
morphine (y 1 ^ grain) hypodermically. It is not, however, a safe prac- 
tice when the body is of sufficient dimensions to completely block up 
the tube, as a rupture below it might possibly take place. 

A smart slap with the palm of the hand, applied between the 
shoulders, is a popular, safe, and sometimes successful procedure when 
the body is lodged high up. 

When a hard angular body is pushed down into the stomach in the 
efforts used for its removal, purgatives should not be administered, but 
firm pultaceous food or dry biscuits may be given with the view of en- 
veloping the object and shielding the intestinal and gastric walls from 
its angularities. A diet of hard boiled eggs is, in the writer's opinion, 
the best means of carrying out this object. 

Where a large or angular body is impacted in the upper part of the 
tube, laryngotomy or even tracheotomy may be necessary to prevent 
suffocation in the presence of severe dys ncea, and even artificial respira- 
tion may be necessary until the body is extracted. Such cases are 
however, fortunately rare. 

Where angular and unyielding bodies, like false teeth aud their ac- 
companying fixings become firmly impacted, there is nothing left for 
the surgeon but to perform cesophagotomy by opening the tube through 
a skin incision four inches long made along the anterior border of the 
left sterno-mastoid muscle. The tube is reached by retracting the 
carotid sheath, sterno-mastoid and omohyoid muscles outward and the 
trachea inward. It is opened over a pair of long curved forceps intro- 
duced through the mouth and made to bulge into the wound through 
the opening. The foreign body is to be extracted with great gentleness 
and the wound in the tube closed with catgut sutures. The skin wound 
and the after-treatment are to be carried out upon ordinary surgical 
principles. 

Cases are recorded in which after artificial teeth with their hooked 
plates had been swallowed and passed into the stomach, where they 
have given rise to severe pains and obstinate vomiting, they have been 
successfully extracted after having been fished up with a money pro- 
bang or coin catcher introduced through the mouth. 

CESOPHAGTJS, Stricture of. 

Practically these are found to be simple — the result of corrosive 
poisons — or malignant. 

The treatment of simple stricture is for the most part embraced in 
the word dilatation. When a bougie can be passed, it should be kept 
in as long as the patient can tolerate it, after which a larger one may 



552 (ESOPHAGUS, STKICTURE OF. 

be tried, and so on until the canal is fully dilated. After corrosive 
poisoning, of course the passage of instruments is unjustifiable until 
considerable healing of the ulcerated spots has taken place, but it is a 
mistake to delay the introduction of a bougie too long. In severe 
cases stricture is almost certain to occur, and if left to itself the canal 
or tube may become entirely stenosed at some point or points in its 
course, hence the necessity of watching such cases and insisting upon 
the passage of the largest possible bougie from time to time, as long as 
any narrowing is found to remain. The writer objects to the ordinary 
olive-shaped bougie, mounted upon the whale-bone stem. He believes 
a well-made gum-elastic solid instrument is a safer dilatiug force, and 
he has had these made with a considerable taper at the point. 

The graduation in size may in the smaller ones reach from about the 
calibre of a No. 4 English catheter at the point to a No. 8 or 9 a few 
inches upward. For long strictures these answer very well. In the 
Dublin Journal, August, 1879, he reported a case which he exhibited 
before the Ulster Medical Society, in which the smallest catheter at 
one time could not be made to pass 1 . Nearly every form of dilator was 
tried, and finally, he used a bougie made of partially dried and fresh 
sea tangle with success. This substance was soft enough to work its 
way through the narrow ulcerated opening without causing pain, and 
yet possessed sufficient firmness to become the medium of conveying a 
safe amount of force. In addition to these qualities, there was, of 
course, the valuable property of its trifling increase in size, as it lay in 
the narrow stricture. After a time, large graduated gum-elastic bou- 
gies were introduced, and the patient made an excellent recovery. 

Where a gum-elastic tube can be passed through the stricture, it 
may be left in situ for several days with the greatest advantage. 

Internal cesophagotomy is a dangerous operation, and with skilful 
use of graduated bougies, it is uncalled for. 

The stomach has been opened by Loreta, and through it a metallic 
dilator has been successfully employed to dilate a stricture situated 
near to the cardiac end of the oesophagus, after which the gastric in- 
cision has been sutured, and the stomach returned to the abdominal 
cavity and the skin wound closed up. 

Where the passage of even the smallest bougie it found to be impos- 
sible, gastrostomy or cesophagostomy will be the only resort left to the 
surgeon. 

The treatment of malignant stricture of the oesophagus is unfortu- 
nately much less satisfactory, at best it can only hope to be palliative. 

There is considerable difference of opinion regarding the advisability 
of dilating a malignant stricture. The writer has satisfied himself that 
by the judicious and gentle passage of a solid graduated gum-elastic 
instrument he has been able to prolong life and relieve suffering, the 
bougie need not be passed more frequently than every fourth or fifth 
day at first. The fear of perforation should always be prominently 
before the surgeon's mind, and force is not justifiable. 



ONYCHIA. 553 

When the passage of liquids becomes difficult there is nothing, as a 
rule, to be gained by the frequent introduction of the bougie. Two 
courses are then open, either to introduce a soft rubber tube through 
the mouth or nose into the stomach for feeding purposes, and allow it 
to remain as long as the patient can tolerate its presence, or else t.o 
adopt Symond's ingenious plan. He inserts into the stricture upon 
the end of a suitable bougie passed through the mouth a short gum- 
elastic tube, with the upper end dilated into a flattened funnel. This 
upper end rests in the dilated part of the oesophagus immediately 
about the stricture, while the tube occupies the stricture, and extends 
below it. A piece of stout silk is attached to the funnel-shaped part, 
and is brought out through some gap in the teeth, and fastened to the 
ear, or in any safe or convenient way. The tube may be left in situ 
for days. Through it liquid food passes easily down to the stomach, 
and often after a time a larger and shorter tube may be inserted when 
dilatation has resulted from its pressure. 

When, through frequent spasmodic cough, the tube can be no longer 
kept in its place, and the stricture gradually closes, and in those cases 
where, owing to the narrowness of the stricture, tubage is from the first 
time that the patient has come under notice impossible, gastrostomy or 
oesophagostomy is the only means by which the surgeon can hope to 
prolong life, or minimize the terrible sufferings attending slow death 
from starvation. 

Rectal feeding should be tried in all cases, even where the patient is 
still able to swallow liquids. (See also under Cancer, page 102.) 

ONYCHIA. 

The old-fashioned treatment is still employed by some surgeons. It 
consisted in the local application of Abernethy's lotion, which consists 
of 2 drachms of liquor potassse arsenitis, and 1 ounce of distilled water. 
This was applied upon lint, which was frequently moistened by fresh 
quantities of the arsenical solution. This method sometimes increases 
the pain and tension of the inflamed tissues. A better application is 
the carbolic or spirit lotion. 

Carbolic acid (1 drachm) and water (4 ounces) make a soothing 
antiseptic lotion, which, being poured upon lint, may be wrapped 
around the last joint of the finger, and enveloped in oiled silk, which 
should be firmly tied at its distal end, so as to form a perfectly im- 
pervious finger-stall. The anaesthetic influence of the acid is most 
grateful, and after a time the ulcerated surface ceases to occasion pain, 
and healing is induced. Chloral (5 or 10 grains to 1 ounce of water) 
may be also used. Iodoform may be dusted over the part, or a mixture 
of iodoform and prepared calamine in equal quantities may be em- 
ployed. 

Finely powdered nitrate of lead is an excellent remedy, and the 
writer has used it successfully in the troublesome onychia attacking 

36 



554 OPIUM HABIT. 

the toes of the young girls employed in the moistened atmosphere of 
flax-spinning rooms. 

Where an ointment is more convenient, the boric acid, tar, mercu- 
rial, or red precipitate salve may be used. 

•Sometimes a free application of a strong solution of nitrate of silver 
at the beginning of the affection leads to a speedy improvement. 

Where exuberant granulations spring up, strong carbolic acid, or 
the liquor ferri chlor. fort., or the liquor ferri sulph. may be brushed 
over them, or tannin or alum may be dusted over the part, or it may 
be daily rubbed with a large crystal of sulphate of copper. 

Where these measures fail, the nail should be removed, and the raw 
matrix dressed with the powdered nitrate of lead. 

In very obstinate cases, where the onychia returns with the growth 
of the new nail, the best procedure is to shave clean off with a sharp 
large scapel the dorsal surface of the last phalanx, removing both nail 
and soft parts, or to remove the nail and destroy the matrix with strong 
carbolic or nitric acid, or with the strong solution of nitrate of mer- 
cury. 

Syphilitic onychia is best treated by the application of a weak cor- 
rosive sublimate lotion, yellow or black wash, or by freely dusting over 
the part with calomel, or by applying calomel ointment spread upon 
lint. 

In such cases internal antisyphilitic medicines are absolutely neces- 
sary, and in strumous subjects constitutional treatment is equally 
necessary. (See Scrofula.) 

OPHTHALMIA— See Conjunctivitis. 
OPIUM HABIT. 

For the treatment of acute poisoning by opium or morphine, see 
under the heading Poisoning. The management of cases is very dif- 
ficult where, from the prolonged indulgence in opium or morphine, 
generally commenced, in the first instance, for the relief of pain, the 
patient becomes so enslaved to its use that a confirmed habit becomes 
established. 

The habit may remain long after the cause for which the narcotic 
was first prescribed has passed away. Not uncommonly the adminis- 
tration of morphine by the hypodermic syringe is the form in which 
the vice is indulged. 

In whatever way the narcotic has been used, when an effort comes 
to be made by the patient to break through the chain which has en- 
slaved him, the physician will have to decide the serious question of 
whether the habit should be broken off suddenly or gradually. 

The former plan is the best in those cases w T here the habit has not 
been long established. It affords in all cases the best prospects of 
success when it can be carried out, though the sufferings of the 



OPIUM HABIT. 555 

patient are most terrible for a time, and liable to be followed by 
collapse. 

When such a course is decided upon, the patient should be under 
the eye of a physician all the time, and a thoroughly reliable and firm 
nurse is an essential part of the treatment. 

The great difficulty in this plan of suddenly stopping the narcotic is 
the effect upon sleep, and provision must be made for this from the 
first. Under Insomnia, the reader will see all the various substances, 
any one of which he may try which does not contain opium or mor- 
phine. The writer has tried almost all of them in the condition under 
notice, and he finds that either paraldehyde or sulphonal is the best. 
It is a good plan to abstain from chloral and Indian hemp, as there is 
much danger of a habit being established by the use of these drugs, 
and the use of sulphonal and paraldehyde upon alternate nights is free 
from any objections. 

Various drugs have been recommended as substitutes for the opium 
during the daytime, but speaking generally, there is little advantage 
in replacing one vice by another. The exception, which may be made 
in the case of alcohol, will be presently referred to. 

Coca may be freely given, and the fluid extract of erythroxylon 
coca is a favorite remedy all through the depression period. The 
danger of the cocaine habit must not be forgotten though it requires 
a longer period for its establishment than the time necessary to wean 
the patient suddenly from his opium or morphine vice. Teaspoonful 
doses of the fluid extract may be commenced, and upon the second 
day, when the symptoms are at their worst, the dose may be given 
every hour. Obersteiner gives cocaine under these circumstances in 
solution by the mouth, and the daily amount during the first two or 
three days is about 8 grains, administered frequently in small quanti- 
ties. After about the sixth day the drug should be stopped entirely. 

Other agents, such as quinine, antipyrine, red cinchona, strychnine, 
etc., have been recommended, but beyond relieving some passing symp- 
toms they are of little use. Diarrhoea, sickness, nausea, and other 
distressing signs are certain to aggravate the sleeplessness, and must be 
met by appropriate remedies. 

The following mixture maybe given every hour or every two hours : 

R.- 



■Ext. cinchonse fid 

Ext. erythrox. fld 

Tinct. cinchonse 


■ • 3* 

• • 3ij. 
• lij- 


Spt. ammon. aromat. .... 
Glycerini purif. 


• 3*1". 

• 3J.-M 



8, — One teaspoonful to be taken every second hour in a wineglassful of 



water. 



The diet should be carefully seen to. In the shock and depression 
caused by the sudden withdrawal of the drug, there is urgent neces- 



556 OPIUM HABIT. 

sity to get in all the nourishing food possible. Strong beef essences 
and concentrated soups, with peptonized milk and other liquid foods, 
should be given at the shortest possible intervals, and a stock of these 
should be laid in before beginning treatment. The question of stimu- 
lants will crop up early, and where there are some reasons against 
alcohol, sal volatile may be freely given in small quantities, and well 
diluted. 

The depression is so terrible that the unfortunate victim, who has 
always got little foretastes of it during the temporary withdrawal of 
his drug upon previous occasions, refuses to submit to treatment unless 
some plan is made clear to him that his sufferings shall be minimized. 

The physician will often be tempted to yield to his solicitations, 
and give some opium during the period of terrible depression, and in 
many cases the treatment breaks down utterly, owing to the alarming 
condition of the patient upon the second day or third morning, when 
it would appear, that to continue the withholding of the drug would 
mean the cost of the patient's life or reason. 

The writer has devised a means which meets the difficulty, and which 
he has carried out satisfactorily in one case. It consists in putting the 
patient under the influence of alcohol, Avhich should be administered 
in such doses as will markedly influence the cerebrum, and keep the 
patient in a state of mild intoxication. The treatment may be com- 
menced six or eight hours after stopping the opium, and it may be 
continued for four or five days, and may be gradually or suddenly 
stopped, as the symptoms indicate. 

In some instances three days may be found sufficient. The writer is 
aware that such a practice is open to serious objections, the chief of 
which is the danger of replacing a serious vice by a worse one. It 
may be said, however, that three, four, or five days' alcoholic excess is 
not likely to lead to the establishment of the alcohol habit ; nor is 
there any serious danger of delirium tremens following. 

This treatment should only be attempted when the medical man can 
give the closest possible supervision to the case, and the patient must be 
carefully watched by a skilful nurse all through. It would appear to 
be most applicable to those apparently hopeless cases where the patient 
is anxious to try and rid himself of his enemy, where he has sufficient 
remnant of will left, and where all other means have been tried and 
failed. 

The physician must always remember, however, in dealing with 
patients who have become the victims of any crave or habit that 
there is always a certain degree of moral perversion present, and 
that in some cases the vice may really be a symptom or result of 
some strain of insanity. In this latter case it is unjustifiable to adopt 
the alcoholic treatment unless the patient can always be kept under 
proper restraint. As a rule, in such cases, even though one vice is 
removed, the patient will, with his perverted moral sense, select 
another ; and such cases are often found to be the victims of both 



OKCHITIS AND EPIDIDYMITIS. 557 

opiates and alcoholic stimulants. If the physician should succeed in 
weaning them off their opium, he will probably find it will be only to 
receive the credit of having made them intemperate. 

Where the gradual plan of treating the patient by steadily dimin- 
ishing the dose of opium or morphine is tried, the diminution must be 
made by fractional increments. Failure generally results in chronic 
cases by the physician's haste or anxiety to make progress, and some 
times the patient is also to blame, being tempted to curtail to an ex- 
tent beyond his power of endurance. Moral treatment, in such in- 
stances, is of the greatest value for a time, and every change in the 
patient's environment may be a benefit, such as the selection of new 
companions, and occupation and change of scene and habits. Coca is 
here of decided value, and it may with advantage be given in combi- 
nation with small doses of antipyrine. Alcohol is especially danger- 
ous, and on no account should chloral be prescribed. The greatest 
difficulty will be from insomnia, and sulphonal, combined with a 
diminished dose of the opiate at bed-time, is the best remedy. As sul- 
phonal is slow in acting, the writer has, in one bad case, obtained very 
satisfactory results in prescribing a dose of 45 grains, thirty or forty- 
five minutes before retiring to rest, and then giving a small opiate just 
as the patient lies down. This prevents the critical period of unrest 
at the beginning of the night, which often is the precursor of intoler- 
able insomnia. Paraldehyde often answers well in large doses (60 to 
90 minims), as it then will induce a drowsy or dreamy quiet state, ex- 
tending well on into the following day, in which the craving for opiates 
may be weakened. 

The plan of substituting cannabis indica or other narcotic occasion- 
ally may be tried, but generally it will not be found to do much good. 
Bromides in full doses always are helpful in quieting the unrest, 
though they often cause much depression. 

Contrary to what he was led to expect, the writer has seen success 
more frequently follow the gradual plan where the hypodermic method 
had been the form of the opium vice than where opiates had been 
taken by the mouth. 

OPIUM POISONING— See Poisoning. 

ORCHITIS AND EPIDIDYMITIS. 

Rest in bed in the horizontal position, lying on the back, is to be 
prescribed when this is convenient. A small board should be placed 
across the front of the thighs, upon this the scrotum can be supported 
as if resting upon a shelf. A board about as thick as the sides of a 
cigar box, only longer, with the upper edge bevelled in the middle so 
as to get well under the scrotum, answers the purpose well. A piece 
of broad strapping may be used in the same way, but it soon becomes 
permeated with moisture. 



558 ORCHITIS AND EPIDIDYMITIS. 

Where the patient must move about, a different method of obtain- 
ing rest for the inflamed gland should be sought. Any of the ordi- 
nary suspensory bandages may be tried. As a rule, they are much 
inferior for this purpose to one which the patient can extemporise for 
himself. This he does by tying a handkerchief, bandage, or girdle 
around the waist, to which another handkerchief (three cornered) is 
attached behind in the middle line, brought down between the thighs 
and fastened again in front of the waste girdle. In this way not only 
is efficient support given to the testicle, but whatever local application 
is selected it can thus be easily kept in contact with the scrotum, and 
at a later stage moderate continuous pressure may be kept up. 
Patients are found to devise various methods by which the suspension 
can be carried out by attaching the bandages to the braces or shoul- 
ders. At the onset, or as soon as the patient comes under notice, a 
smart saline purgative should be given. One ounce of Rochelle salt 
in a bottle of aerated lemonade is an efficient and palatable dose. In 
very plethoric subjects sulphate of magnesia may be given in tea- 
spoonful doses, so as to keep up brisk purging for a time. 

Where there is much constitutional disturbance a diaphoretic and 
antiphlogistic mixture like the following may be given : 

R. — Tinct. veratri vir Tllxvj. 

Liq. amnion, acet. . . ^ij. 

Vini antimonii ^j. 

Aquae campkorse ^v. — M. 

S. — One tablespoonful to be taken every second hour. 

In very severe cases the saline may be preceded by one large dose 
of calomel, though there is generally little to be gained by this as the 
saline acts more quickly. Pulsatilla is said to have a specific effect in 
orchitis. It may be combined with aconite. The diet should consist 
of milk and kali water or whey, rennet, and mucilaginous drinks, 
solids and animal food being forbidden. One large opiate at night 
with bromide of potassium is a valuable method of giving ease and re- 
lieving pain. Local treatment is of importance. Where the patient 
is seen early a bladder of ice or a cold evaporating lotion continually 
changed is the best application. A cambric handkerchief, dipped in 
iced water, with small pieces of ice laid in between its folds is an effi- 
cient method of applying cold. Some surgeons employ a modification 
of Leiter's tubes. 

Where pain and tension are aggravated by continuous cold, warm 
poppy fomentations are grateful, and even poultices, smeared over 
with the extract of belladonna, may be employed. Where orchitis 
occurs as a complication of parotitis this will be the safest plan of 
treatment. Where epididymitis occurs as a sequel of gonorrhoea, in- 
jections of astringent or antiseptic solutions must be stopped, and 
though the rule is laid down that all urethral medication must be sus- 



ORCHITIS AND EPIDIDYMITIS. 559 

pended, the writer has seen good results from steady perseverance with 
injections of warm water, sterilized by a few drops of Condy's fluid. 

Where there is great pain, swelling, and tension, any of the following 
procedures may be adopted : 

1. The scrotum may be painted over with a solution of nitrate of 
silver (1 : 6). 

2. Leeches may be applied to the neck of the tumor or to the groin. 

3. Any of the large scrotal veins may be opened with a lancet. 

4. Several short incisions may be made into the swollen or cedema- 
tous tissue of the scrotum. 

5. A fine trocar may be driven into the cavity of the tunica vaginalis, 
and any hydrocele fluid permitted to escape. 

6. A series of punctures with a stout needle or fine trocar may be 
made into the substance of the testicle or swollen epididymis. 

7. Pressure may be applied to the swollen gland either by means of 
plaster or the pressure of an elastic bag or suitable bandage. These 
plans of making compression are at first very painful, but are said to 
be soon followed by marked relief. 

Seldom will any of these procedures be required. The great majority 
of cases yield in periods varying from forty-eight hours to six or eight 
days to the treatment first mentioned. 

Collodion has been used as a mild method of causing compression, 
as it contracts after drying. Should signs of suppuration show them- 
selves, a free incision into the fluctuating point should be made, and 
the w r ouud treated by a weak sublimate solution or other antiseptic 
lotion, or dusted over with iodoform. 

Where there is much induration or tbickness left after the subsidence 
of the inflammation, the lin. potassii iod. cum. sapone, B. P., is the best 
local application, spread upon lint and applied to the scrotum. Over 
this, by strapping or by means of a laced elastic bag, firm and steady 
pressure may be continuously kept up. Some surgeons prefer to use 
mercurial ointment; the iodide liniment often brings out an eruption. 
Iodide of potassium should be given internally in these cases, after the 
subsidence of the acute symptoms. 

Orchitis, or epididymitis following gouty inflammation of the urethra 
yields to rest, warm fomentations, or hot poultices, and the administra- 
tion of full doses of colchicum wine combined with salicylate of sodium 
and the occasional use of cathartic doses of sulphate of magnesia. 

Chronic orchitis being in the great majority of instances a syphilitic 
affection, constitutional as well as local treatment will be required. 
The constitutional remedy is, of course, mercury or iodide of potassium. 
There are few cases in which more marked evidence can be observed of 
the power possessed by these drugs in causing the absorption of inflam- 
matory products. 

The administration of mercury will be decided by the history of the 
case. In weak cachectic subjects who have suffered from syphilis very 
many years previous to the appearance of the orchitis, and w r ho had 



560 ORCHITIS AND EPIDIDYMITIS. 

been'previously brought well under the influence of mercury at least 
once before, it will be wiser to begin with large doses — 10 to 15 or even 
25 grains of the iodide of potassium three times a day. In all other 
cases mercury may be given in amount and in the manner indicated 
by the symptoms and history of the case. Thus in comparatively 
recent cases the patient should be brought under the influence of the 
drug without unnecessary delay by inunction or by the administration 
of moderate doses of any mercurial preparation. (See under Syphilis.) 
It will never be necessary to cause salivation, but the drug should be 
pushed until the gums are slightly touched, after which the effect may 
be kept up for long periods, without injury to the patient, until the 
induration in the testicle melts away. 

In very chronic cases the iodide may be combined with mercury, and 
the writer has obtained excellent results from Donovan's solution : 

Be . — Liq. arsenii et hydrarg. iod. . . . . . 5 jss. 

Aquse dest ad ^ iv. — M. 

S. — One measured drachm to be taken after food in a wineglassful of water 
three times a day. 

The bichloride of mercury may be given in a mixture with the 
iodide of potassium. The following is an efficacious combination in 
such cases: 

R. — Hydrarg. chloridi corros. . . . . . gr. ij. 

Potassii iodidi gij. 

Aquae dest B xr J- — M- 

S. — One tablespoonful after meals in water three times a day. 

The mercurial suppository is a favorite means of administering the 
drug with the older surgeons. The younger school often resort to 
fumigation or vaporization in the treatment of syphilitic orchitis. 

Local treatment may be summed up in the words pressure and mer- 
mercurial ointment. Where hydrocele complicates the case — a very 
common occurrence — time will be saved by first tapping the tunica 
vaginalis, and, after the evacuation of the fluid, applying lint smeared 
over with ungt. hydrarg., and then, by means of strips of stout adhesive 
plaster, applying a firm pressure to the swollen gland. 

Where the system is already under the influence of mercury, the 
mercurial dressing may be omitted and plain soap plaster applied direct 
to the shaven scrotum. This is often the only treatment necessary in 
dealing with a chronic orchitis which is not syphilitic, such as where 
considerable induration or enlargement follows the subsidence of an 
acute attack of orchitis or epididymitis, or follows upon an injury. 

Where the induration is localized to a portion of the epididymis or 
body of the testicle, or in those cases where pressure cannot be toler- 
ated, a little mercurial ointment may be rubbed in with the finger. 



OTORKHCEA. 561 

In non-syphilitic cases the best remedy to employ is the liniment of 
iodide of potassium with soap (B. P.). This may be firmly rubbed in 
with moderate pressure morning and night until the skin becomes tender. 
Iodine in the form of U. S. P. tincture, may be applied with a brush 
daily; it often causes much irritation and sometimes oedema of the 
scrotum. 

When pain or tenderness exists the mercurial preparation may be 
diluted with an equal amount of the unguentum conii, or 10 to 15 per 
cent, of the green extract of belladonna may be combined with it. The 
oleate of mercury with morphine may be employed with benefit. 

The following may be tried : 

&• — Oleati hydrargyri 5 1 ^- 

Ungt. conii (B. P.) , £ iv. 

Ext. belladonnas 3J- — ^1- 

S. — Use as directed. 

In malarial subjects quinine should be given in large doses. In 
gouty orchitis of a chronic nature, salicylate of soda may be given in 
doses of 15 grains twice a day, and i a grain of the extract of colchi- 
cum may be administered at bed-time every night. 

When the above treatment has been followed out for a few weeks 
the organ generally diminishes in size and consistency, and the irue 
testicular sensation returns. Rarely will castration be called for, unless 
in neglected cases where the surgeon may find the testicle hopelessly 
destroyed by abscesses or softened gummata. During the treatment 
by mercurials and pressure the patient can generally be permitted to 
walk about or pursue his usual avocation, all sexual exercises being 
strictly forbidden. 

Close attention to diet, and to every means by which the general 
health can be improved must not be neglected, and at a later stage 
cod-liver oil, tonics, chloride of gold, or arsenic and strychnine com- 
bination with iron, and sea bathing will be very valuable. 

OS OALOIS, Diseases of— See Caries and Necrosis. 

OSMIDROSIS — See Perspiration, Excessive, and Bromidrosis. 

OSTITIS— See Periostitis 

OTALGIA— See Ear, Diseases of. 

OTITIS— See Ear, Diseases of. 

OTORRHCEA. 

As this is but a symptom of some purulent catarrh or deep-seated 
lesion in the middle ear, the treatment recommended under the head- 
ing of Ear Diseases, page 221, is to be followed. 



562 OVARY, INFLAMMATION OF. 

The most scrupulous cleanliness is to be maintained, while the reme- 
dies indicated for the treatment of the affection which has led to the 
otorrhcea are being employed, such as dilatation of the Eustachian 
tube, etc. Syringing with tepid water, to which enough Condy's fluid 
has been added as will just color it, is to be carefully carried out twice 
or three times a day, and after all accumulations of pus and thickened 
discharges have been flushed out by the stream of liquid, finely pow- 
dered boric acid is to be blown in with an insufflator. The haphazard 
methods of injecting irritating solutions as injections of iodine, pure 
spirit of wine, nitrate of silver, chlorinated soda or lime, strong car- 
bolic acid, iodoform, chloral, sulphate of zinc, chloride of zinc, corrosive 
sublimate, etc., are to be strongly condemned. 

Where the bland and unirritating action of the boric acid fails in 
diminishing the amount of secretion, a weak solution of the sulphate 
of zinc may be tried. Two grains to the ounce answer all purposes. 
When the fetor is very marked the amount of the permanganate of 
potassium, which is added to the tepid or warm water, should be gradu- 
ally increased as long as its injection fails to produce pain. One grain 
of bichloride of mercury in one ounce of pure or absolute alcohol may 
be used as a solution in which a little cotton wool may be saturated 
and gently pushed loosely into the canal, where it may be left from 
time to time, the excess of solution finding its way toward the tympanic 
cavity. The plug should not be such as will interfere with the free 
exit of the purulent discharge. 

Chrystie insists upon the strictest antiseptic treatment of purulent 
otorrhoea, and records cases where a few applications cured the disease 
when of many years duration. All specula, forceps, etc, are thoroughly 
sterilized with strong carbolic solution or red heat, the canal and fundus 
of the ear are carefully dried out by borated wool and the fundus 
mopped absolutely clean with carbolized(l : 40) cotton tufts. After 
gently drying out, a powder is insufflated, consisting of six parts of boric 
acid and one part of iodoform. 

M. Shield dwells upon the failure of producing a perfect aseptic con- 
dition in perforative otorrhoea by the use of lotions or insufflations, 
and he incorporates the antiseptic remedy with oil of theobroma by 
making a pellet or minute suppository which can be easily introduced 
into the meatus. 

OVARY, Inflammation of. 

The treatment of acute oophoritis will consist of perfect rest in bed, 
in the most comfortable position which the patient can discover. This 
is generally lying upon the back with the legs drawn up. 

One smart purge, such as 6 drachms of Rochelle salt, should be at 
once administered, and when it is slow in acting it may be hastened by 
using an enema of warm water. 

Leeching is recommended, and the cervix, groin, and peritoneum 



OVARY, INFLAMMATION" OF. 563 

may be the seat of application. The writer has never seen a case 
requiring leeches. 

Hot fomentations or poultices over which belladonna extract has 
been smeared may be used to give relief. Counter-irritation by 
means of cantharides, mustard, turpentine stupes, etc., may be tried, 
but for a time such measures appear to increase the pain. When 
this is very severe, opium is necessary ; it may be given in very 
acute cases in the form of a full dose of the hypodermic injection 
of morphine (ti to i> grain), or as a morphine suppository (? grain), 
or as 1 grain of the watery extract of opium, every four or five hours, 
by the mouth. 

The best local application will be the following, sprinkled freely over 
a circular piece of spongio-piline and applied to the ovarian region 
(above the groin). It may be w T orn for hours, a little fresh liquid 
being sprinkled on from time to time : 

R . — Lin. belladonna 1 z • 

. Y ...... aa 3jss. 

Lin. chloroformi J 

Lin. camphorse ........ ^j. — M. 

S. — To be used as directed. 

As the violence of the pain- subsides, the effects of the opiates may be 
kept up after their suspension by moderate doses of antipyrine, and 
30 grains of bromide of potassium at bed-time. 

Cannabis indica is a good narcotic when opium or morphine cannot 
be used. 

At a later stage mild counter-irritation to the iliac region by a 
daily application of the tincture of iodine may be resorted to with 
advantage. 

The treatment of chronic oophoritis will tax the patience and 
resources of the physician to their utmost. Owing to the very chronic 
nature of the affection the treatment cannot be conducted upon the 
same principles as those which safely guide the physician in acute 
cases. Thus, absolute rest, to be of any value, must extend over periods 
so protracted as to seriously injure the patient's general health and vigor. 
Nor can opiates with safety be employed, as the danger of establishing 
the opium or morphine habit is very great. 

Both these remedies may, however, be employed, under cautious 
restrictions, during the acute exacerbations which often supervene, 
especially about the menstrual period, when too much exertion or 
exposure to changes of temperature has been indulged in. 

While every means is being employed to improve the general 
health, any possible cause of the ovarian irritation is to be carefully 
sought out and remedied. Constipation must be treated thoroughly, 
and the patient's own statements are not to be relied upon in this 
matter. It is not a rare event to find that upon making a vaginal 
examination the rectum or sigmoid flexure is loaded with feces, 



564 OVARY, INFLAMMATION OF. 

though the patient may affirm that the bowels have been naturally 
relieved a short time previously, the rectum only partially expelling 
its contents. 

Oascara and enemata of tepid or cold water must be daily employed 
(see the remedies mentioned under Constipation) until the bowels are 
Drought into a healthy condition. 

Chills to the extremities, and cold feet, prolonged standing, or 
wearying exercises must be avoided, and sometimes the occupation of 
the patient should be changed for one affording more regular alterna- 
tions of open-air exercise and rest. Sexual intercourse should be very 
much restricted. 

The only sedatives which can be employed with safety in such a 
chronic condition are the bromides. They may be given in full doses 
in combination with the iodide of potassium and a little belladonna or 
conium. 



K . — Sodii broniidi . 
Potassii bromidi 
Potassii iodidi . 
Tinct. belladonnse 
Aquse chloroform! 
S. — One dessertspoonful to be taken 
water, after meals. 



• 3iij- 

• 3iij- 
ad ^viij. — M. 

hree times a day in a wineglassful of 



In addition to the sedative action of such a combination, it will have 
some absorbent effect upon any effused products resulting from the 
long-standing inflammation. 

Antipyrine or antifebrin maybe given in moderate doses during the 
periods when pain is more than usually prominent, or during the inter- 
vals in which the above mixture is suspended. Hydrastis is often very 
useful, and ergot may be advantageously given when subinvolution is 
present. 

Local treatment may be employed in the majority of instances with 
marked benefit. It may be directed to probable causes, such as flex- 
ions or versions of the uterus or prolapse of the affected ovary. 

A comfortably-fitting Hodge's pessary, with the posterior or sacral 
end composed of India-rubber, often gives great relief, as does also a 
rubber ring, with steel spring enclosed. They place the posterior cul- 
de-sac upon the stretch, and support both the relaxed uterus and the 
displaced ovary. 

The writer obtains the greatest satisfaction in these cases from the 
introduction of a Graily Hewitt's cradle pessary, shaped like a Hodge 
bent upon itself in the middle, the two wings being connected in their 
middle and lowest points by a cross bar. Such an instrument, though 
difficult of insertion and still more inconvenient for removal, never falls 
out or gets displaced, and invariably gives comfort. If too large a size 
be used, the prolapsed ovary may be compressed between the posterior 



OVARY, INFLAMMATION OF. 565 

wing of the instrument and the sacrum, though the writer has never 
known this to occur when the pessary is inserted upside down — i. e., in 
the reverse position to that used for anteversion. 

Copious vaginal injections of hot water may be used twice daily, 
and if the rectum pipe of the enema apparatus be carefully inserted 
by the side of the pessary, its presence will be no impediment to their 
use. 

The writer hesitates to express an opinion upon a practice which has 
the sanction of eminent specialists ; but he is inclined to believe that 
copious hot water vaginal injections, consisting, say, of one or two gal- 
lons, should not be permitted in patients moving freely about unless a 
pessary be worn at the same time. 

Any ulceration of the os or cervix should be treated by appropriate 
remedies, such as the application of iodized phenol or nitric acid, though 
Barnes recommends that a small raw surface, produced by the applica- 
tion of London paste, should be kept open upon the cervix. The same 
result may be obtained bv lightly brushing over the os with the iodized 
phenol or tincture of iodine. 

Counter-irritation over the iliac or inguinal region by means of a 
small cantharides blister, kept open by dressing with D'Albyspere's or 
other irritating plaster, is often useful. Iodine, capsicum, or sinapisms 
may be substituted. The anodyne liniment, mentioned upon page 563, 
to be applied upon spongio-piline, may be employed to relieve pain, even 
when the patient moves about. Rest, as already mentioned, may be 
absolutely necessary at the menstrual periods, and when the exacerba- 
tions of pain become very severe, at this time hot sitz or very warm hip 
baths may be safely prescribed. 

Electricity is often recommended ; but in simple oophoritis it may 
lead to increase of the pain, though occasionally a, weak continuous cur- 
rent may be employed with great advantage by passing it through the 
lower part of the abdomen, between large electrodes, placed one over 
the ovarian region and the other over the sacrum. 

By applying the positive pole to the cervix or interior of the uterus 
and the negative outside the abdomen, pain is often markedly re-" 
lieved. 

Uterine massage, with elevation of the uterus and gymnastic exer- 
cises, performed by forcible separation and forcible closure of the knees, 
have been much praised in the treatment of chronic oophoritis, but 
there is room for very sharp differences of opinion regarding the wis- 
dom of such a practice. 

Where, notwithstanding all treatment, the affection continues to 
harrass the patient, the question of removing the diseased ovary or ova- 
ries must be seriously considered. The after consequences must be 
weighed against the benefits lightly to accrue, and, if the patient con- 
sents, every other means having failed, the operation of removing the 
prolapsed and diseased organs may be undertaken. This may be done 
best, as a rule, by opening the abdomen in the median line and remjv- 



566 OVARIAN TUMORS. 

ing both ovaries, as in the operatian of ovariotomy. The removal of 
prolapsed and adherent ovaries by tho vagina is less satisfactory. 

OVARIAN TUMORS. 

The various methods of treatment which were in former times (before 
the brilliant achievements of modern surgery were dreamt of) employed, 
with the forlorn hope of curing or preventing the progress of the growth, 
have fallen into disuse. 

Thus, drugs for internal administration, as iodides, mercurials, diu- 
retics, etc., are known to be worthless, and are now never depended 
upon. Injections of iodine and other substances into the tumor are now 
little practised, though by injecting simple monocystic ovarian tumors 
in former years, sometimes excellent results were obtained. Sir James 
Simpson, for instance, had only one failure in twenty cases, though 
other surgeons have reported most unfavorably of the operation. It 
often fails entirely, and sometimes causes death ; and the practice is 
now rapidly becoming replaced by excision. For multilocular cysts it 
is absolutely worthless, and only in typical cases of monocystic tumors, 
where the diagnosis is clear, is it worth trying. 

In a large ovarian cyst of many years' duration which came under 
the writer's notice when its contents had become purulent, and were 
oozing through a minute orifice at the umbilicus, it was apparent that 
it had formed adhesions in every direction and to the abdominal wall, 
excision appeared to him to be out of the question, and he recommended 
one large incision into the suppurating cavity of the cyst where it was 
adherent to the parieties, and the establishment of thorough drainage 
and washing out with antiseptics. This was done with complete 
success. 

Tapping or aspiration of the contents of an ovarian cyst is a prac- 
tice which the most experienced specialists in this department are 
steadily condemning. In some cases of cysts in the broad ligament, 
their tapping has effected a cure, and Keith still adopts this method of 
treating all such cases ; but for the treatment of cysts of the ovary, 
success is much rarer than the supervention of serious drawbacks, such 
as hemorrhage, peritonitis, suppuration, etc., which occasionally have 
caused death, or which often have led to the formation of extensive 
adhesions, the presence of which has seriously affected the removal of 
the tumor at a later stage. 

There can hardly be a doubt about the wisdom of totally discarding 
the tapping of ovarian cysts as a means of cure, independent of ex- 
cision or ovariotomy. In a limited number of cases the writer has 
seen one death directly follow tapping of a large cyst by a skilful sur- 
geon. Occasionally, for purposes of diagnosis, tapping may be neces- 
sary, and it is well, if in such a case, the operation of ovariotomy could 
be immediately proceeded with. 

Tapping is admissible as a method of giving relief in cases where an 



OVARIAN TUMORS. 567 

operation is unjustifiable, as in a patient suffering from cancer or other 
incurable affection, or as a method of tiding the patient over pulmonary, 
renal, or other embarrassments, caused by the pressure of the tumor, 
until her general condition becomes so improved as to warrant opera- 
tion. 

The tapping should be conducted under the strictest antiseptic pre- 
cautions. A long, fine trochar and canula, after being well washed in 
a weak sublimate or strong carbolic solution, may be plunged into the 
cyst in the middle line, midway between the umbilicus and pubes, as 
the patient lies upon her side close to the edge of the bed. 

To the canula is attached a long piece of rubber tubing, the free end 
of which is dropped into a pail containing a little carbolic lotion. This 
precaution prevents the possibility of air being allowed to enter the 
cyst. The instruments devised by Wells, Thompson, Tait or Ward 
Cousins answer well. The writer has generally used the largest sized 
trochar and canula belonging to Dieulafoy's aspirator. Aspiration is 
seldom necessary, and large trochars, such as formerly were used, are 
not advisable. 

After the contents of the cyst have been drained or syphoned off by 
the above method, a small pad of lint may be placed over the open- 
ing, and kept in position by a few strips of plaster, and a broad band- 
age or binder should be applied as tight as comfort will permit, and 
the patient should be directed to lie upon her back for the first twenty- 
four hours, as this may diminish the chances of the cystic fluid drib- 
bling into the peritoneal cavity. 

The operation of ovariotomy is, by the common opinion of surgeons, 
recommended to be undertaken before the tumor has assumed large 
proportions. It is admissible, however, in the most advanced stages of 
ovarian degeneration, and has become the safest and most satisfactory 
major operation in surgery, as remarked by Greig-Smith, who quotes 
the remarkable results of Tait, in which no death resulted after 139 
ovariotomies. The reader is referred to any of the special works upon 
the details of ovariotomy, as only a brief sketch of the operation is 
here admissible. 

The most suitable time for operating is about four to eight days 
before the next catamenial discharge is expected. 

The patient should have the bowels well cleared out by a mild 
cathartic or warm water enema, and the catheter should be passed be- 
fore the operation is commenced. No food is to be permitted for three 
or four hours before the administration of the anaesthetic, and then an 
egg beaten up with milk or a large cupful of strong beef-tea should be 
all that she is allowed. An ordinary night-dress over which a warm 
flannel jacket is worn, and woolen stockings on the legs, afford the 
most convenient and comfortable dress as the patient is placed upon 
the operating table. The front of the abdomen should be thoroughly 
cleansed by carbolic lotion ; and after chloroform, ether, or A. C. E. 
mixture has been administered, and the surgeon has seen that every pre- 



668 OVARIAN TUMORS. 

caution has been taken to avoid unnecessary chilling of the surface of 
the body during the operation by the suitable disposal of warm 
blankets or cotton wool, the abdomen is exposed and a large mackin- 
tosh sheet, sufficient to cover the trunk and to project beyond the feet 
of the patient, is laid over her. This sheet has an oval aperture, whose 
margins are smeared over with adhesive plaster, by means of which it 
is fastened to the abdominal parieties, leaving the sight of the incision 
uncovered and corresponding to the oval, while it covers over and pro- 
tects from moisture the entire trunk and legs of the patient, and pro- 
jects beyond the limits of the operating table as she lies upon her back 
with the head and shoulders slightly raised. 

All instruments are to be soaked in warm carbolic solution (1 : 40), 
out of which they are to be lifted as required, and the operation should 
be performed under the carbolic spray (1 : 20). Sponges, after re- 
peated beatings in order to remove sand, and frequent washings for 
many hours under a tap, should be soaked for at lead twenty-four hours 
in a strong solution of carbolic acid (1 : 20 or 1 : 30). They should 
be carefully counted over before and after operation, prior to the closing 
up of the abdomen, so as to prevent the possibility of any being left 
behind. 

Each operator has his own list of instruments. The following will 
meet most cases of ovariotomy : A scalpel or straight bistoury ; at least 
one dozen of Wells's or Tait's hemostatic forceps'; one or two pairs of 
ordinary artery forceps ; two pairs each of large and medium cyst for- 
ceps (Wells's or Nelaton's) ; one vulsellum ; one Tait's large and one 
Wells's small or medium cyst trochar, with rubber tubing ; scissors ; one 
Adams's hook ; two mounted pedicle needles ; one needle-holder and 
needles; sutures; one clamp ; cautery irons ; drainage-tubes. 

The incision is made in the middle line, its length depending upon 
the size of the emptied cyst, its lower limit should be two inches above 
the pubes, and its upper may be necessarily prolonged close to the left 
side of the umbilicus. Sometimes an incision two inches in length 
may suffice, and the writer has seen ten inches necessary in one case. 

The first few strokes of the knife should divide for about two inches 
all the structures down through the fibrous aponeurosis until the trans- 
versalis fascia is reached. Bleeding points are to be secured by artery 
forceps, and the peritoneum is then to be opened by knife and director, 
or scissors, as in hernia operations. 

With the exposure of the cyst the operator should at once proceed 
to tap it without venturing to explore or break down adhesions, and 
after the fluid has ceased to run, any secondary cysts are to be also 
emptied through the original opening or broken down by the insertion 
of the hand or fingers. When this has been accomplished the operator 
makes gentle traction upon the collapsed tumor, while he explores for 
adhesions, which are to be broken down by the fingers or by the pres- 
sure of a sponge if very soft and recent. In the separation of adhe- 
sions the greatest patience and judgment are necessary to determine 



OVARIAN TUMORS. 569 

the amount of force justifiable. Adhesions which are so firm as to 
resist traction short of producing rupture of organs, must be treated 
by excising the adherent portion of the cyst-wall and leaving it in situ. 
After the removal of all adhesions the collapsed and flaccid cyst is 
gently extracted through the abdominal opening, which may have to 
be enlarged for this purpose. As the tumor is withdrawn from the 
abdomen, the pedicle is brought into view ; the treatment of this is 
open to grave variations. Some surgeons tie it in one mass, others tie 
it in sections ; the stump has been left outside, returned into the cavity, 
clamped, cauterized, twisted, tied with catgut, wire, and silk. The 
clamp and cautery method is still used by some operators, but the rule 
may be generally said at present to be transfixion of the pedicle by an 
armed mounted needle, and the tying of each half with a stout silk 
ligature, cutting the pedicle moderately close with a knife and drop- 
ping the ligatured end back into the abdomen. A large flat sponge is 
placed over the intestines as soon as the tumor has been extracted, and 
before the pedicle has been secured. 

After the pedicle has been satisfactorily disposed of, the operator 
proceeds to clean out the abdominal cavity, removing by the gentle 
and diligent use of soft sponges squeezed out of warm carbolic lotion 
every vestige of blood or foreign matter from the peritoneum. Sponges 
held in long ovum or polypus forceps should be pressed down into the 
hollows about Douglas's space and frequently withdrawn and reapplied 
until there is nothing to take away. Tait washes out the abdominal 
cavity when there has been much foreign matter exuded. This he 
accomplishes by pouring in large quantities of warm water and moving 
the intestinal coils about with the hand until the water flows out clear. 
Any bleeding point caused by the separation of the adhesions is to be 
secured by catgut or silk ligatures, twisted or touched by the thermo- 
cautery or chloride of iron. 

When the toilet of the peritoneum has been satisfactorily carried 
out, several dry sponges may be placed in the most dependent parts of 
the abdominal cavity and left there until just before the closing up of 
the wound by the approximation of the sutured edges. A glass drainage- 
tube (Keith's) should be inserted where there is any reason to expect 
weeping, especially in cases where there has been troublesome adhesion 
of the cyst- wall to the deep parts of the pelvis. The end of the tube 
should dip down deeply into Douglas's po'uch. It will seldom be re- 
quired in cases operated upon antiseptically. Sutures are to be carded 
through all the structures entering into the abdominal parietes, the 
lowest one being inserted first. The peritoneum is also to be embraced 
in the sutures, close to the margins of the wound. Before adjusting 
them all sponges are to be removed and the drainage-tube (when nec- 
essary; inserted. The edges of the wound are to be accurately brought 
together, without placing too much tension upon the sutures. A pad 
of several layers of carbolic gauze is laid over the line of incision, and 
held in its place by a series of broad strips of adhesive plaster, which 

37 



570 OVARIAN TUMORS. 

should 'ex teriti from each loin to the opposite, so as to firmly support 
the entire abdomen. When this is properly done there is little neces- 
sity for an abdominal binder, though no harm can result from placing 
a neatly-fitting broad flannel bandage or binder over the whole, and 
where the distention has been very great a large pad of cotton wool or 
a large folded napkin may be secured in its place over the strapping 
by the flannel, so as to give additional support and to minimize the 
sensation of emptiness which the patient often feels. 

The after-treatment of ovariotomy is of vital importance, and as it 
often falls into the hands of the ordinary medical attendant after the 
departure of the specialist who has operated, he should, study it more 
carefully than the steps of the operation. 

The best position for the patient after operation is upon her back in 
bed, upon a good hair mattress, with the shoulders and head elevated 
and the legs supported or raised by a pillow placed under the knees. 
It is, however, a mistake to insist upon this or any other position 
against the instinctive feeling of the patient should she desire to turn 
over upon her side. One matter must be impressed upon both patient 
and nurse — i. e., that when a change of posture is desired it should be 
accomplished slowly and deliberately by the assistance of the nurse. 
Hot-water bottles or extra clothing for the first few hours may be 
necessary. 

Regarding diet, Smith recommends for the first twenty-four hours 
nothing but small quantities of hot water or hot toast-water; in the 
next twenty-four hours a little oat-meal gruel or Brand's essence of 
meat given with the water. Afterward, he states, " If the case is doing 
well the patient may have almost \vhat she asks for." This latter 
advice is to be accepted with caution, and unless the case is in the 
hands of a most discreet and experienced nurse, it should be the duty 
of the physician to look closely after the diet. If vomiting supervenes, 
a little ice may be permitted. 

The writer has seen much mischief produced by ice administered 
too often and in too great quantities. When thirst is great, Smith's 
plan of giving an enema of one pint of tepid water is often most 
efficacious. The fear of inducing vomiting should lead the nurse to 
give as little of anything as possible by the mouth. Water may 
accumulate in the stomach after ice has been given too freely, and 
vomiting may be thus produced. When the operation has been a 
severe and protracted one, as soon as the patient is permitted two or 
three hours rest, three or four ounces of warm strong beef- tea should 
be injected into the rectum by an India-rubber bottle and pipe of a 
capacity not greater than the amount of the injection. Some operators 
begin and continue rectal feeding in every case as a matter of routine 
for the first three or four days. This is often unnecessary, and the 
risk of producing rectal irritation or uneasiness should not be lightly 
undertaken. 

Milk is condemned as a food by many, but this is probably because 



OVARIAN" TUMORS. 571 

it has been injudiciously administered. After the first efght hours or 
so, a tablespoonful of milk mixed with an equal quantity of effervescing 
potash water, is a convenient, safe, and agreeable method of intro- 
ducing nourishment into the stomach, but during the first twenty-four 
hours the total quautity administered should not exceed at the most 10 
ounces of milk. 

During the secoud day this amount may be doubled, if all goes well, 
and no nausea or vomiting be excited. 

The milk may be, however, soon suspended for beef-tea, cold chicken 
jelly, or warm chicken soup, if relished. The danger to be avoided is 
in forcing nourishment too frequently upon the patient. Arrowroot, 
fine sago, or farola may be given in small quantities after the first 
twenty-four or thirty-six hours. Weak tea and thin bread and butter, 
or dry toast, may be permitted upon the third or fourth day, and fish, 
chicken, or a little lean chop upon the fourth or fifth, and after about 
the seventh day ordinary diet may be cautiously commenced. The 
complications and symptoms which occasionally arise will, of course, 
modify the above dietary, signs or symptoms of peritonitis forbidding 
the administration of animal food. 

The routine practice of administering opium or morphine imme- 
diately after every ovariotomy is objectionable. These should only be 
given w T hen pain is complained of. The best form is the morphine 
perule, and -J- grain will generally be sufficient. It can scarcely be 
vomited owing to its minute size and spherical form, and perules, 
containing Jg grain, may be given every two, three, or four hours, 
when necessary. 

The forms of suppository and hypodermic injection are preferred by 
many, but the perules appear to check nausea and vomiting. In those 
cases where rectal feeding is necessary the opiate may be judiciously 
administered in the form of laudanum mixed with the enema. 

Thornton recommends frequent washings out of the stomach by means 
of a soft rubber tube, where peritonitis exists in conjunction with bilious 
or dark vomiting. 

Where tympanitis or severe abdominal distension supervenes early, 
the rubber tube may be passed up the rectum ; but this seldom does 
any good, and it is a mistake in such a case to wait until the sixth or 
seventh day before having the bowels relieved. A smart saline purge 
given upon the third or fourth day generally affords speedy relief, and 
often appears to ward off the threatened peritonitis. 

Four drachms of Rochelle salt dissolved in 5 ounces of aerated 
lemonade may be given, and repeated, if necessary, in five or six hours, 
though some physicians prefer a dessertspoonful of castor oil. 

The catheter need not be passed for twelve or eighteen hours after 
the operation, unless the patient expresses uneasiness, as there is 
generally but a small amount of urine secreted at first. The catheter 
should be kept scrupulously clean, and each time before and after use 
it may be dipped into the glycerin of borax (1 : 6), which effectually 



572 OVARIAN TUMORS 

prevents the •introduction of any living organism into the bladder or 
urethra. Its application should not be delayed beyond every twelve 
hours at the most after the first day. If the patient be unable to pass 
water without assistance, every eight hours will generally be found to 
answer. 

The wound will require little attention. It need not be touched until 
the expiration of seven days, unless a drainage-tube has been inserted. 
Where this has been found to convey but a little oozing, it may be 
removed after the first day, and the aperture closed by a suture inserted 
loosely at the time of operation. At the end of the first week in 
ordinary cases the pad of gauze is to be removed with the strapping by 
bathing or moistening the parts with warm carbolic lotion. The 
sutures are also to be snipped and removed, a fresh pad of gauze 
adjusted, and bands of adhesive plaster applied as before to give sup- 
port to the abdominal parieties. The binder may be re-applied, and 
the wound again left undisturbed for another week, at the end of 
which it will generally be found to be thoroughly united. 

About fourteen days is generally found to be a sufficiently long 
period for keeping the patient in bed. After this time she may be 
permitted to sit up, and in three weeks may leave her apartment, and, 
if a suitable bandage is applied, she may be permitted to drive about. 
She should be cautioned to take rest and special care during the first 
and second menstrual periods succeeding the operation. 

When the temperature is found to rise after the operation, it may be 
wise to give some simple diaphoretic mixture and await events. The 
surgeon should not attach too much importance to the elevation of tem- 
perature, as trivial causes may send the thermometer up several degrees, 
while dangerous peritonitis may be present with a fractional increase 
of body heat. 

Where the fever continues high, some means must be employed to 
reduce it. The ice-cap, or Leiter's tubes to the forehead or scalp, 
is often resorted to. It is doubtful if these produce any marked 
effect in cases which warrant any antipyretic remedies. 

Persistent high temperature must be met by prompt action, and 
hyperpyrexia, though rare, will probably soon prove fatal unless 
speedy reduction of temperature is effected by active remedies. 

In one case — a patient of the writer's — the temperature reached 
108° inside of twenty-four hours after the operation. In such a case 
probably no treatment is of any use, but the only means worth trying 
is the cold wet pack, which may be applied to the entire body, and the 
sheets so frequently changed or saturated with iced water until the 
tempeiature falls to the normal. Mild cases yield to iced cloths 
placed over the legs and thighs and arms, but in high temperatures 
the trunk must be also included in the pack. 

Where the rise of temperature is persistently high, and accompanied 
with great distention of the abdomen, the surgeon should strive to treat 
the cause. Where this is owing to the accumulation and retention of 



OVARIAN TUMORS. 573 

decomposing secretions within the abdomen, steps should, if possible, 
be taken to give ^xit to the offending matter when the condition of the 
patient looks grave. 

This may be accomplished by the removal of the sutures from the 
lower half of the wound, and the thorough washing out of the abdominal 
cavity by a copious stream of warmed antiseptic liquid, as weak carbolic 
lotion or boric solution. The surgeon should introduce his fingers or 
hand into the cavity, and separate any agglutinated coils of bowel, and 
in bad cases of peritonitis the abdomen has been successfully re-sponged 
out and the wound sutured up again. In all such cases there must be 
free drainage established, and the glass tube should be inserted deep 
into Douglas's pouch with the collar resting between the edges of the 
abdominal wound. A loose roll of carbolized or iodoform gauze is 
placed inside the tube, and a carbolized sponge over its open extremity. 
When the tube remains in situ, the gauze in its interior draws up any 
moisture. This percolates also into the sponge. These should be 
renewed every eight or ten hours under the carbolic spray, and some- 
times, when the discharge gets scanty, a Tait's suction apparatus may 
be employed. 

Some surgeons in these cases puncture the pouch of Douglas through 
the vaginal walls by means of a long trochar and canula which is 
left in the wound, or a drainage-tube is inserted as the canula is with- 
drawn. 

The temperature, when depending upon causes such as have been 
referred to, generally falls upon the drainage being provided. If not, 
it is certainly worth while to give an antipyretic. Quiuine is not 
generally reliable. The amount necessary to make a decided impres- 
sion upon the temperature often upsets the stomach and digestion. 
Antipyrine is safe and convenient, and may be given in doses of 15 
grains every four or six hours until the temperature falls to normal. 
In peritonitis this must be given by the rectum, as vomiting is so con- 
stantly present. For the same reason all feeding by the mouth must 
be given up, and the patient should be fed entirely by enemata of beef- 
tea or peptonized foods. Greig-Smith's routine enemata consists of: 
1 ounce of brandy, 1 drachm of Valentine's liquid beef, or 1 drachm 
of Brand's essence, or 1 drachm of Benger's peptonized jelly, and 4 
ounces of peptonized milk. 

This is to be given every four or five hours, and once in the twenty- 
four hours an enema of tepid water, to the amount of 1 pint, is to be 
administered, and the rubber rectum-tube worn for about an hour 
before each enema. 

These precautions are necessary, as it is most undesirable and some- 
times dangerous to allow the decomposing or putrid remains of the 
enemata to lie and accumulate in the rectum, especially as the mucous 
membrane may have suffered some abrasions from the frequent intro- 
duction of the anal tube. 

With the rectal feeding, and small quantities of ice by the mouth, 



574 OXALURIA. 

and an antipyretic when needed, there only remains for the peritoneal 
inflammation full and continuous doses of morphine. 'The best way to 
administer this is to give one full dose by the hypodermic method, 
after which the effect may be kept up by giving a perule containing 
Jg- grain every hour by the mouth until the pupils are markedly con- 
tracted and pain relieved. 

Turpentine enemata rarely do any good, and they may seriously 
interfere with rectal feeding by setting up irritation. 

OXA.LIC ACID POISONING— See under Poisoning. 

OXALURIA. 

There is no special or specific treatment for this condition. In every 
case the first thing to do is to determine the cause of the impeded 
metamorphosis, and have this removed or corrected. Where this is 
caused by some error in digestion or assimilation, suitable tonics are 
indicated, and by far the most valuable are the mineral acids, 20 
minim doses of the diluted nitrohydrochloric acid in infusion of 
calumba being very useful. When over-eating is the cause, especially 
when much animal food and acid wines are indulged in, the best treat- 
ment will be a wise regulation of diet and strict temperance in all 
things. Often rhubarb brings on very severe oxaluria, and saccharine 
foods sometimes produce the same effect. 

The writer has seen the condition disappear upon changing the eat- 
ing habits of the patient. Thus the heavy dinner indulged in after 
partially fasting all day may be the cause of oxaluria, and by getting 
the patient to dine in the middle of the day, and to take a light meal 
in the evening, the amount of oxalic acid or oxolate of lime becomes 
rapidly diminished. Large eaters should take a bottle of simple car- 
bonated or aerated water instead of tea ; concentrated soups are not to 
be recommended. 

Want of free exercise in the open air often leads to retarded meta- 
bolism, and a change of life in this respect may lead to the speedy 
disappearance of oxaluria when the ill-ventilated office or workroom 
is abandoned for the fresh breezes of mountain or seaside resorts. 
Sleeping-room ventilation should be looked after, and the bedroom 
window left open all night is an advantage. For the anxious, over- 
worked city clerk who drives to his small office in the morning, and 
drives home again in the evening to spend the hours until bed-time in 
the close atmosphere of a gas- heated room, the suggestion of tricycle 
or bicycle exercise is a good practice. 

Sleep should be sound and natural, and all conditions interfering 
with this must be attended to, neuralgia, insomnia, overwork, or high 
pressure being remedied as far as this is possible. 

Sea bathing, the Turkish bath, or, better still, a good shampooing or 
massage after perspiration has been induced by brisk or even violent 



ozjenx. 575 

exercise, is of use. The morning shower bath is to be recommended, 
and the clothing should be warm and waterproof. 

Roberts recommends the administration of small doses of the bicar- 
bonate of potassium when the signs point to gastric irritation, and the 
mineral acids when atonic dyspepsia is present. 

To sum up, the treatment of oxaluria will consist in the vigilant and 
persevering lookout for the violation of some health law, which, being 
discovered, should be at once remedied. 

OZiBNA. 

The treatment of this unpleasant affection may be summed up in 
the words — absolute cleanliness. Where this is rigidly and persever- 
ingly carried out, the worse cases may be expected to yield. 

The great difficulty in dealing with ozsena is to remove the thick- 
ened secretion upon whose presence the fetor depends. Every crust 
should be washed away, and no mucus be allowed to accumulate. As 
long as secretions are permitted to remain, decomposition speedily sets 
in, and the diseased surface is never placed in a condition favorable 
for healing. Hence the necessity for the persistent use of the nasal 
douche, which consists of a soft rubber tube, with a nose piece at one 
end and a lead sinker at the other. This latter is dropped into a jug 
of warm water, in which a teaspoonful of common salt or bicarbonate 
of sodium is dissolved, and after starting the fluid to run syphon- wise 
through the tube, the iug is elevated as the end of the douche is in- 

O 'JO 

serted into one nostril. By keeping the mouth wide open the soft 
palate is raised and the posterior nares cut off from the mouth and 
pharynx, and as the water flows in through one nostril it courses 
around the nasal chambers and flows from the other nostril. 

This should be continued until every trace of thickened secretion is 
removed, and at first, or in neglected cases, hot fomentations and inha- 
lation of steam may be employed to assist in the removal, and where 
the dried discharge adheres to the roof of the nasal cavity, an ordinary 
enema syringe may be employed to wash it out, or it may be mopped 
out by pledgets of cotton wool twisted around a probe. 

After a few applications of the douche, its constant employment be • 
comes a comparatively easy matter, and if used three or four times a 
day, the mucus or pus has not time to desiccate, and a few minutes are 
sufficient to cleanse the cavity. During the douching, the nose-piece 
should be taken out of one nostril and inserted into the other. 

When the crusts are removed, and antiseptic solution should be sub- 
stituted for the salt or bicarbonate of sodium liquid. Every known 
substance possessing deodorising properties has been recommended or 
used, of which a few are subjoined : 

Permanganate of potassium (1 grain or 1 drachm of Condy's fluid 
to 10 ounces of water). 

Chloride of zinc, 2 grains in 10 ounces of water. 



576 OZ^EJSTA. 

Sulphate of zinc, 8 grains in 10 ounces of water. 

Jayes' disinfecting liquid, 20 minims in 10 ounces of water. 

Carbolic acid, 1 drachm in 10 ounces of water. 

Sanitas fluid, 1 tablespoonful in 10 ounces of water. 

Chlorinated soda solution, 1 teaspoonful in 10 ounces of water. 

Nitrate of silver, 4 grains in 10 ounces of water. 

Sulphurous acid, 2 drachms in 10 ounces of water. 

Alum in powder, 30 grains in 10 ounces of water. 

Borax, 40 grains in 10 ounces of water. 

Chlorate of potassium, 20 grains in 10 ounces of water. 

Tannin, 30 grains in 10 ounces of water. 

Tincture of iodine, 15 minims in 10 ounces of water. 

Boroglyceride, 2 drachms in 10 ounces of water. 

Boric acid, 1 drachm in 10 ounces of water. 

Naphthol (see below), 5 to 10 grains in 10 ounces of water. 

Hydrate of chloral, 5 grains in 10 ounces of water. 

Bichloride of mercury, 1 to 2 grains in 10 ounces of water. 

Any of the above solutions may be used, and the surgeon will be 
wise who confines himself to the use of any one or two of them, instead 
of changing from day to day. The astringents in the list may be 
selected where the discharge is copious, and the deodorizers are indi- 
cated in proportion to the amount of fetor present. 

Beta-naphthol has been most successfully employed by Rualt. He 
washes out the nose with a fresh solution of 60 graius of borax and 
the same amount of bicarbonate of sodium, in 1 pint of water, to which 
a teaspoonful of the following solution is then added — i. e., naphthol 
(beta-naphthol), 1 drachm, dissolved in 1 ounce alcohol (90 per cent.). 
In obstinate cases he inserts for fifteen minutes, after using the above, 
cotton tampons saturated with the following : 

R. — Naphthol (beta-naphthol) ..... gr. xij. 

Tinct. quillayse 3jss. 

Aquse dest. . . . . . . . q. s. ^j. 

Sidlo has obtained excellent results by the use of glycerin. He 
washes out with a 2 per cent, solution of potass, chlor., to which 10 per 
cent, of glycerin is added. After removal of all thickened secretion, 
he inserts for one hour daily, cotton tampons saturated in glycerin, 1 
part, and water, 3 parts. 

Rossenbach paints the interior of the nose with Peruvian balsam, 
and leaves tampons saturated with it in contact with the deeper parts 
of the cavity. This treatment effectually destroys all fetor. 

Boric acid, bismuth, camphor, tannin, calomel, and iodoform, suit- 
ably diluted with chalk, sugar or starch, have been used for insuffla- 
tion, but they are less satisfactory than liquid preparations. 

After the use of any of the above irrigating liquids, the speculum 
may be employed, and any ulcerated spots may be touched with strong 



pain. 577 

solutions of the same antiseptic agents, with iodized phenol, ethyl 
iodide, chloride of iron, ethylate of sodium, the galvano- or thermo- 
cautery, nitrate of silver, or nitric acid. 

As a rule, ulcers rapidly heal under constant irrigation by weak 
saline or antiseptic solutions. 

When diseased bone is present, little improvement may be expected 
until this has been removed, which, as a rule, can be easily accom- 
plished by seizing any loose bone in a pair of small sequestrum or 
stout dressing forceps, and gently dragging it through the nostril. 
When the dead bone is too large for removal in this way, or when it 
cannot be easily reached, Rouge's operation of turning up the lip, and 
dividing the mucous membrane and all the structures above the ante- 
rior teeth by a horizontal incision, may be tried. After detaching the 
cartilaginous septum from the anterior nasal spine, the finger may be 
passed into the nasal cavity, and by the aid of suitable forceps any 
diseased structures may be removed. 

Lowenstein uses, with great success, the new drug aristol or iodide 
of thymol, in ozama, and relates the details of a case where iodoform 
failed entirely, and where insufflations of aristol caused the intense 
fetor to vanish, the ulcers to speedily heal, and the crusts to cease from 
forming. 

Syphilitic ozsena will require similar local treatment, a very weak 
solution of corrosive sublimate (1 : 5000 or 1 : 10.000) being freely 
used for irrigation. Any ulcerated spots will require to be cautiously 
touched with the solution of nitrate of mercury, and loose or diseased 
bone must be removed. Calomel may be insufflated in such cases with 
advantage. 

Constitutional treatment is of great importance in ozama, and is as 
urgently required in the strumous as in the syphilitic cases, the reme- 
dies suitable for these varieties being noticed under scrofula and 
syphilis. 

In every case the general health is to be maintained by good food, 
pure air, change of scene, tonics, cod-liver oil, iron, iodides, arsenic, 
quinine, sea bathing, etc., from the very beginning of the local 
treatment. 

PAGET' S NIPPLE— See Nipple, Disease of, page 542. 
PAIN. 

The treatment of pain will be detailed with the treatment of various 
diseased conditions in which pain is a prominent symptom, as neuralgia, 
cephalalgia, peritonitis, sciatica, megrim, etc. 

PALATE— See Cleft Palate 

PALPITATION— See Heart, Diseases of. 



578 PARALYSIS AGITANS. 

PANCREAS, Diseases of. 

Of the pathology and symptomatology of these affections little is 
known, and of their treatment still less. In malignant disease the 
treatment will resolve itself into measures for the relief of pain, though 
surgical treatment has been advised, but the operations cannot be 
considered justifiable in the present state of our knowledge. Acute 
and hemorrhagic pancreatitis are practically beyond the reach of art. 

Cystic disease of the pancreas has been successfully operated on by 
tapping, by abdominal section and attempted excision, and by estab- 
lishing permanent fistulous openings in the abdominal parietes and 
other methods. Of all plans the most uniformly successful is that of 
incision and drainage. 

In one case where a large tumor formed after a severe injury to 
the abdomen, the writer tapped the tumor, the contents of which were 
found by Professor Matthew Hay to consist of pure pancreatic juice. 

Gallons of this fluid were removed from time to time, but the 
patient did not suffer from any of the symptoms supposed to always 
follow the arrest of the secretion of the gland, though the enormous 
quantities of fluid, possessing in a very active form all the physiologi- 
cal qualities of undiluted pancreatic juice, continued to be removed 
by the aspirator for many weeks. The tumor, after one of the tappings, 
rapidly filled up with a bloody liquid. Symptoms of peritonitis 
supervened, and the patient made a rapid and complete recovery, 
and remained perfectly well five or six years after the tappings. 
When last seen, the pancreas showed no signs of the presence of any 
cystic growth, the patient being well nourished and vigorous. In 
chronic pancreatic disease the use of pancreatized food or of Benger's 
preparation is indicated. 

Calculi, when detected, may be submitted to manipulation or taxis 
which has been successful in a few cases. If this fails, abdominal 
section may be entertained. 

P ANNUS— See Conjunctivitis, page 138. 

PARALYSIS— See under Hemiplegia, Spinal Meningitis, Mye- 
litis, Caries of Vertebrae, etc. 

PARALYSIS AGITANS. 

The treatment of this affection is most unsatisfactory ; eminent 
authorities have reported great improvements in several cases following 
the use of remedial agents, which, upon further clinical experience, 
have proved valueless. The most hopeful therapeutist will hardly be 
likely to continue to push drugs which do not give evidence of doing 
some good inside a reasonable time, and yet the best treatment may be 



PARALYSIS AGITANS. 579 

found ultimately to consist in the exhibition of some agent whose action 
is very slow. The writer has prolonged the trial of various substances 
generally to find that in the end the case pursued its own course. The 
reports of cases which speedily commenced to improve after the use of 
certain agents are not to be wholly discredited. The explanation pos- 
sibly lies in there being a moral or psychological effect following their 
administration. Reports of cases where a permanent improvement or 
cure followed the use of any line of treatment are exceedingly rare, 
though it is related that Brown-Sequard cured one case with chloride 
of barium, Elliotson another with subcarbonate of iron, and Reynolds 
a third with galvanism applied to the spine. 

The best effects are probably secured by the prolonged use of arsenic 
internally and a continuous current applied to the affected muscles or 
limbs. Fowler's solution may be given in doses, commencing with 3 
minims, increased gradually to 10 minims three times a day after food, 
and a current from 8 to 16 Leclanche cells may be sent through the 
affected region daily for ten to twenty minutes. Sometimes good effects 
have been observed by injecting Fowlers solution (2 or 3 minims) 
subcutaneously, or deeply into the muscles. 

Chloride of barium appears to possess remarkable power over some 
cases, It may be given in doses of I grain, three times a day. 

Valerian, in large doses, 10 grains of the extract, or dessertspoonful 
doses of the simple tincture may be tried. The writer has seen good 
effect from the valerianate of zinc, but only when given in such doses 
as cannot long be taken without upsetting the digestion and appetite, 
and causing headache — i. e., 5 to 8 grains three times a dry. ^"o result 
folio v,s the ordinary dose of 1 or 2 grains. 

In hyoscine we have a remedy about whose action there cannot be 
any doubt. Erb has given it with remarkable benefit. It acts speedily, 
and has been found to stop the movements with tolerable certainty, 
and often they have been found not to return for a considerable period 
after the action of the drug had ceased. It is given hypodermically 
in doses of yi-g- grain of Merck's preparation. 

As yet there is, however, little evidence forthcoming of its permanent 
effects, and in an affection of such long duration there are grave objec- 
tions to the use of powerful remedies which only give temporary relief. 
(See fifth edition of the "writer's volume on Materia Medica, page 
572.) In severe cases of the disease where the movements seriously 
interfere with the patient's rest, it is of the greatest possible advantage 
to possess such a remedy, and by its use life may be comfortably pro- 
longed ; but such cases are rare. Moderate support to the affected 
limb may be also of use in severe examples of the disease, though any- 
thing like restraint as bandaging to splints, etc., aggravate the mischief. 
Bandaging may be useful in the early stages of the disease. In very 
mild cases of short duration a mixture like the following may be given 
for long periods : 



580 PARALYSIS, DIPHTHERITIC. 

R. — Tinct. hyoscyami ^jss. 

Liq. Fowleri giij. 

Tinct. Valerianae ^ iijss. 

Glyeerini purif. 3 v. — M. 

S. — One measured drachm to be taken three times a day after meals in a little 
water. 

Strychnine, phosphorus, atropine, iodide of potassium in large doses, 
opium, calabar bean, chloral, bromides, ergot, curare, and many other 
drugs have been employed, but with very little benefit to tempt one to 
hope for permanent improvement. 

Cod-liver oil and iron may often prove useful in improving the tone 
of the general health, and hydropathy has unquestionably done good. 
In the next case falling under the writer's care, he intends to try the 
effect of massage, performed for a long time. 

Recently, suspension, as used in the treatment of locomotor ataxia, 
has been recommended. (See page 458.) 

PARALYSIS, Diphtheritic. 

There are few affections in which the physician may more safely in- 
dulge the hope that by his interference he can often prevent a fatal 
syncope and save life. 

The treatment of diphtheritic paralysis is simple, it resolves itself 
chiefly into a question of feeding. The disease is certain to disappear 
completely if the patient's life can only be sustained long enough for 
the elimination of the poison causing the paralysis. This is, however, 
sometimes a very slow process, and when the cardiac or respiratory 
muscles are affected there is great danger of a sudden wind up to the 
case, and the physician must be on the look-out for the first symptoms 
of cardiac weakness which are to be met by free stimulation and am- 
monia. In the very onset of the paralysis, occurring sometimes within 
a few days after recovery from diphtheria, or during the course of the 
disease, the heart muscle may be the first to suffer from weakness, and 
when the first symptoms of this are overlooked by the physician, sud- 
den death may be the first change which shows the effect of the diph- 
theritic poison. As soon as the pulse, or temperature of the chilled 
extremities show any evidence of cardiac weakness, the patient must 
be treated with promptness. He should be put to bed and warmth 
with friction applied to the limbs, while a small sinapism is applied 
over the heart, and whiskey or brandy given in warm milk, both by 
the mouth and by the rectum. Ammonia, in the form of strong 
liquor may be applied to the nostrils and sal volatile in fall doses, 
well diluted, may be administered every fifteen or thirty minutes, 
while faradization of the precordial region may be resorted to in 
severe cases. 

In the more common form of the affection where the weakness be- 



PARALYSIS, DIPHTHERITIC. 581 

gins in the lower extremities or in some of the peripheral muscles, as 
in the eye or palate, the paralysis comes on at a later period often 
within a fortnight or month after recovery from diptheria ; though the 
danger of sudden cardiac failure is much less, these cases are apt to be 
very tedious, and before recovery almost every muscle in the body may 
become paralyzed. Feeding should be rigorously attended to, and as 
soon as swallowing becomes difficult or impossible rectal alimentation 
must be commenced. In every way that is possible the nutrition of 
the body is to be improved, and when the appetite is weak, tonics, such 
as the well-known combinations of quinine, diluted nitro-hydrochloric 
acid, and tincture of bitter orange, are to be resorted to. Moderately 
active exercise in the open-air when exercise is possible, and when 
walking is difficult, the patient should be carried out to sit or recline 
in the sunshine, or be pushed in a bath-chair. Where these are im- 
possible, as in the middle of winter, indoor exercise and general mas- 
sage may be tried, and the appetite coaxed in other ways, as by 
unusual variety of choice and carefully cooked foods administered 
often. 

When digestion shows signs of failing, pepsin wine may be freely 
given after every meal, or a little alcoholic stimulant may be per- 
mitted. Food should be peptonized, and all enemata must be par- 
tially digested before administration. (See page 171.) In bad cases 
the patient should be roused up at least once during the night to 
receive nourishment, and in the case of children this must be done 
often er. 

The writer has seen a patient almost completely paralyzed after diph- 
theria, in which swallowing even of liquids was altogether impossible. 
Standing was out of the question, the patient being unable to turn in 
bed, and respiration threatened to stop from respiratory paralysis. 
Recovery ensued in this apparently hopeless case by rectal feeding 
with peptonized beef tea, milk, and eggs, and inunction with cod-liver 
oil, and the application of the cod-liver oil bandage already described 
(page 507.) 

Drugs are useful ; but before referring to their internal administra- 
tion it must be emphasized that they hold a secondary place in com- 
parison with the importance and value of feeding by the mouth and 
rectum. 

Iron is the most reliable. It may be given at any stage of the 
affection, and in any form which the peculiarities of the case suggest. 
It appears to do best in those cases where it was not freely adminis- 
tered during the 'progress of the primary affection. The dialyzed 
preparation appears to act better than any other, especially as it is 
much less likely in large doses to interfere with the digestion or 
bowels. Some authorities strongly recommend the various natural 
iron waters, and when combined in the form of an effervescing mix- 
ture they agree when the dialyzed liquor or the favorite carbonate or 
saccharated carbonate is not relished. Small doses should be tried 



582 PAKALYSIS, DIPHTHEEITIC. 

when large or fall quantities disagree. Blanchard's pill of the iodide 
of iron may be administered for long periods without giving rise to 
unpleasant results. 

Arsenic is sometimes useful ; but it is only indicated in very tedious 
cases, and then when combined with iron. 

Strychnine or nux vomica is a remedy of great value ; but it should 
never be given in the acute stages of the paralysis. In the later stages 
it may be given by the mouth, or in very chronic cases it may be in- 
jected with much benefit into the weakened muscles. 

The following is a good routine formula for internal administra- 
tion : 

R. — Stiychninee . 

Tinct. ferri chlor. 
Quininse hydrochlor. . 
Glycerini purif. . 
Aquse dest. . 
S. — One measured drachm to be taken three times a day after meals in water. 

Electricity is open to the same objection as strychnine — i. e., that in 
whatever form administered it does harm in the early stages. Asa 
later period its value cannot be doubted, and in a very chronic case 
the writer found that improvement ceased as soon as galvanism was 
suspended. 1. A weak current may be passed from the spine to the 
affected muscles. 2. The healthy contractility and irritability of the 
muscles should be maintained by placing the kathode of a continuous 
galvanic battery upon the skin over the motor points, and then rapidly 
making and breaking contact by alternately applying to and with- 
drawing the anode from the skin over some indifferent places near to 
the affected muscles. 3. Local faradization of the muscles may be 
practised with beneficial results. 4. A weak continuous current may 
be sent through the peripheral nerves of the affected limb or region. 
The applications of electricity should be only made from five to ten 
minutes once daily. 5. Static electricity may be employed. 

Where the paralysis has resisted all these means, and the muscles 
continue to waste, massage may be tried two or three times a day, and 
stimulating embrocations and even blisters have been advised. The 
Chilli paste containing powdered capsicum is an excellent local appli- 
cation, though Cormack preferred a paste composed of — 

R. — Pulv. zingiberis . . . . . . # 3 V J- 

Pulv. sinapis ^ij. 

Adipis prseparati ....... q. s. — M. 

S. — To be used as directed. 

With this paste circular bands of linen or lint, about an inch in 
breadth, are smeared and applied at intervals of five or six inches to 



PARALYSIS, INFANTILE. 583 

the whole length of the limb for several hours daily. By changing the 
position of the bands the entire surface of the limb may be kept in a 
state of continuous mild counter-irritation. After the partial subsi- 
dence of the irritation, deep or parenchymatous injection of small doses 
of strychnine affords the best chance of speedy recovery. 

PARALYSIS OP FACIAL AND OCULAR MUSCLES— See 
under Paralysis Peripheral. 

PARALYSIS, Infantile, 

or acute atrophic paralysis, or poliomyelitis anterior acuta. Where 
the physicion is fortunate enough to see the case at the very beginning, 
or where he is still more fortunate in being able to make a diagnosis, 
antipyretics and diaphoretics are indicated ; but absolute rest at this 
stage is the chief indication. The ice-bag to the head and spine has 
been advised, but its utility is doubtful. A smart saline purge follow- 
ing a moderate dose of calomel should be tried, and afterward iodide 
of potassium in moderately large doses may be given. 

Most cases, however, do not come under observation until the para- 
lysis has been thoroughly established for a variable time, and, as the 
only remedy to be relied upon in the treatment of infantile paralysis 
is electricity, the question at once crops up — what is the earliest period 
at which the use of this agent is justifiable ? This question may be 
answered easily by stating that if a mild or very weak continuous cur- 
rent be judiciously used the treatment may be commenced generally 
as soon as the patient comes under observation — i. e., toward the end of 
the first week or middle of the second. The writer used galvanism 
earlier than this in one case with much benefit ; but if the faradic cur- 
rent be employed it will be wise to postpone its application until a later 
period. 

This current, though used by Duchenne, should not be employed in 
the early stages when a continuous battery can be obtained. It is pain- 
ful, and, in the case of children, generally causes great excitement. 
Moreover, owing to the reaction of degeneration being established, the 
weak continous current will provoke strong and slow contractions 
where the faradic current produces nothing but pain and irritation. 
Hence in the treatment of acute atrophic paralysis we may safely make 
a rule of always employing the weak continuous current at the onset, 
and as long as the muscles fail .to react to faradism. 

The galvanic current is applied in two ways, large sponge electrodes 
being employed, one being placed upon the vertebrae behind, and the 
other on the front of the body, and by changing or reversing them in 
this way a moderate current may be made to transverse the affected 
region of the cord in both directions for about two minutes daily. The 
other method is of more importance. It consists in galvanizing the 
affected muscles by placing the anode on the spine, while the kathode 
is passed over the muscles, contact being made and broken frequently. 



584 PARALYSIS, GENERAL, OF THE INSANE. 

Both methods may be tried at each sitting, which should last for a few 
minutes at first, until five, ten, or fifteen minutes daily be spent in this 
way for several months. Excellent results follow even when this treat- 
ment has been delayed for many months, and some authorities have 
reported great improvement even after twelve or eighteen months, but 
the greatest perseverance and patience must be exercised, and the cur- 
rent must not be strong. At a later stage the continuous may be sus- 
pended for the faradic current with advantage from time to time, and 
this applies also to the treatment of the chronic form of atrophic para- 
lysis as well as to the acute, whether occurring in children or adults. 

Massage of the affected limb is of the greatest service. The nurse 
or mother of the child can be easily taught to carry this out two or 
three times a day by pinching up and rolling the affected muscles be- 
tween her middle finger and thumb, and the writer has obtained excel- 
lent results by rubbing in cod liver oil at the same time. Stimulating 
applications, as the liniment of camphor, Chilli paste, or the paste of 
rose Cormack mentioned under Diphtheritic Paralysis, may be also 
used ; and local brine baths, or sea-bathing and hydropathy, are very 
useful. Strychnine may be tried by the mouth and hypodermically. 
The later method is sometimes of great value when the daily injections 
of Jq- grain are carried down into the muscles. Tonics, as quinine, 
iron, arsenic, cod-liver oil, and malt extracts, with change of scene and 
plenty of good food and fresh air, are essential. Contractions of unop- 
posed muscles must be met by appropriate orthopedic measures and 
gymnastics. 

PARALYSIS, General, of the Insane. 

The treatment of this hopeless malady has hitherto been purely 
expectant, but a new era in its history has been marked by Claye 
Shaw. Believing that the pathological appearances pointed to irrita- 
tive (probably inflammatory) processes in the upper layers of the con- 
volutions in the earlier stages, and to the pressure of resulting fluid, 
and remembering that increased arterial tension was generally a marked 
sign, he was led to trephine at an early stage in the disease. He be- 
lieved that in this way he could relieve tension, and set up a changed 
nutritive process, and consequently H. Cripps trephined a patient upon 
the right side of the skull over the central sulcus, about two inches out- 
side the longitudinal fissure, making two apertures and removing the 
intervening bone, leaving a window about one and a half inch long, 
and about half this extent in breadth. 

The dura mater was excised and a considerable quantity of sub- 
arachnoid fluid removed, and the most marked improvement rapidly 
followed. The mental signs of exaltation, and convulsive attacks 
which had been present disappeared, and the patient became quite 
sane. 



585 

PARALYSIS, Alcoholic. 

If the patient be seen in the early stage of the disease there will be 
every reason to believe that an absolute cessation of indulgence in 
alcohol in every form will enable him to recover. Suckling has pointed 
out that recovery may be even expected where the disease has lasted 
over a year. If, however, the muscles fail to respond to the interrupted 
current, and the reaction of degeneration be present, he points out that 
treatment must be very perseveringly tried before benefit begins to 
appear. Treatment in all cases will consist in total abstinence from 
every form of alcohol, rest in bed, the judicious use of the continuous 
and interrupted currents, with daily massage and counter-irritation by 
means of a series of flying blisters over the course of the nerve-trunks. 

Internally and hypodermically strychnine is the only remedy to be 
relied upon. The general management of the case may be carried out 
upon the lines mentioned under Diphtheritic Paralysis. 

PARALYSIS, Peripheral. 

Under this heading may be included all cases of local paralysis not 
depending upon disease of the spinal cord or brain ; it includes paral- 
ysis of spinal as well as of cerebral nerves. The chief indication for 
treatment will be, in the first instance, found in the removal of the 
cause, when this is possible. Diligent search should be made in every 
case for any compression upon the nerve in its course. Tumors of 
various kinds, and abscesses may, by pressing upon the nerve-trunks, 
produce both sensory and motor paralysis, and in such cases removal 
of the cause must be accomplished before any improvement can be 
expected. Reflex causes, as carious teeth, are to be treated upon 
similar principles. Blows, over-exertion, exposure to cold and damp, 
and other common causes will also afford obvious indications for treat- 
ment. 

The routine management of the paralysis is such as has been already 
mentioned under Diphtheritic Paralysis, i. e. : 

Counter-irritation to the nerve-trunk and entire limb. 

Massage applied to the affected muscles. 

Strychnine hypodermically in the later stages of the affection. 

Electricity — using the form of current which is found to most easily 
produce muscular contractions in the affected limb. 

The most suitable method for the majority of cases will be found in 
placing the anode over the nerve-trunk, on the skin above the lesion 
or over some indifferent part, and applying the kathode over the motor 
points as contact is rapidly made and broken. The "labile" method 
may be used w T ith great advantage by placing the anode over an indif- 
ferent part, as the kathode is slowly moved over the skin covering the 
affected muscles and nerves; or the "stabile" method may be tried. 
Large moistened Isponge electrodes should be used. In any case the 

38 



586 PARALYSIS, PERIPHERAL. 

faradic current should be occasionally employed, the electrodes being 
applied directly over the affected groups of muscles in turn. 

In paralysis affecting the facial nerve, and often known as Bell's 
paralysis, the mild cases get well rapidly without any treatment, but 
in the severer form of the affection the resources of the physician will 
be sometimes severely taxed. In the early stage leeches may be ap- 
plied behind the ear and to the auricle. One large blister applied 
over the mastoid process is, however, likely to be followed by better 
results than local blood-letting. Hot fomentations and poultices are 
to be avoided, as are also sinapisms. After leeching or blistering, a 
very large and thick pad of absorbent cotton-wool is to be applied over 
the side of the head, and kept in its place by a bandage or night-cap 
with strings. One large saline purgative having been administered, 
the following mixture should be commenced : 



R . — Potassii iodidi .... 
Potassii bromidi 
Syr. aurantii .... 

Aquae camph _ 

S. — One tablespoonful to be taken in water. 



. 9iv. 
• Bvij. 

. ad ^viij.— M. 
after meals, three times a day, 



This may be continued during the first three weeks of the affection. 

There is much difference of opinion regarding the time at which 
electrical treatment is to be commenced, and also regarding the form 
of electricity best suited for the affection. The writer believes that 
the best results are obtained from faradization commenced early 
(within the first week). He bases his conclusions upon a limited 
number of cases, but of one of these he was himself the patient, having 
suffered from a severe attack after exposure in a snow storm in 1872. 
Erb believes that the constant current is of little benefit until the 
restoration of the conductivity has occurred. The kathode should be 
placed over the paralyzed muscles while contact is made and broken, 
and when the continuous current is selected the breaks should be rapid. 
This current may, with great advantage, be used when, from paralysis 
of the chorda tympani and the filaments going to the stapedius and 
palate muscles, it is shown that the seventh nerve is affected high up. 
In these cases a weak continuous current may be passed through the 
head by placing an electrode over each mastoid process. The same 
result may, however, be brought about reflexly by faradization of the 
fifth nerve on the face. 

In chronic cases the writer has seen unmistakable success follow the 
injection of strychnine over the site of the chief branches of the nerve 
in the face. He has injected ^V grain, beginning with 2 or 3 minims 
daily of the B. P. liquor (1 : 100). 

Bichloride of mercury in small doses is indicated after the iodide has 
had a good trial, and, where there is any reason to suspect syphilis, it 
may be administered from the beginning. 



PSEUDO-HYPERTROPHIC. 587 

Paralysis of the third, fourth, or sixth nerves (peripheral) is to be 
treated upon the same principles — viz., leeches and blisters behind the 
ear or over the temple, large doses of iodide of potassium, and, in 
syphilitic cases, of mercury. Galvanism is also useful, and may be 
employed by passing a very weak continuous current through the eye- 
ball and brain by placing the anode over the occiput and the kathode 
over the closed eyelid. 

PARALYSIS, LANDRY'S-See Myelitis. 

PARALYSIS, LEAD— See under Plumbism. 

PARALYSIS FROM PROGRESSIVE MUSCULAR ATROPHY 
OR WASTING- PALSY. 

The remarks made under the head of Infantile Paralysis apply, 
almost without modification, to the treatment of the present affection. 
Drugs are practically of no value. Any benefit to be expected can 
only be obtained from electricity, and this may be applied in the same 
manner as for infantile and diphtheritic paralysis (which see). The 
usual nerve remedies may, however, have a fair trial — arsenic, phos- 
phorus, chloride of gold, and iodides can do no harm, and they may 
be given with cod-liver oil, Where a syphilitic history is clear, great 
good may be obtained from large doses of the iodide combination with 
small quantities of the bichloride of mercury. 

The general health is to be maintained in the highest state of per- 
fection, and great care should be bestowed upon the clothing, the 
patient being well encased in flannels, and if the affection is vigorously 
and persistently treated by galvanism from the earliest stages there is 
a fair prospect of improvement. The writer has seen marked improve- 
ment for a time to follow the use of the continuous current, even when 
the disease was advanced. 

PARALYSIS, Pseudo-hypertrophic. 

The treatment of this affection is almost hopeless. Probably the 
few cases which recover are uninfluenced by the remedies which have 
obtained the credit due to the vis medicatvix naturce, though Duchenne 
thought that at least two cases yielded in his hands to the faradic cur- 
rent. Bourdel and Henoch also each report a case w T here electricity 
was successful in the early stages. Both forms of current may be 
steadily employed, and Benedikt galvanizes the sympathetic. 

Massage, brine baths, and hydropathy may also be tried ; but little 
may be expected from the plan of Greisinger, who advocates the com- 
pression of the calf muscles by bandaging. 

In the later stages no treatmeut appears to have any effect, and until 
something is definitely knowm about the pathology of the disease little 
can be expected from drugs. Arsenic, strychnine, iron, iodides, phos- 



588 PARAPHIMOSIS — PEDICULI. 

phorus, etc., have been tried without result. The writer reported a 
case in the Medical Times and Gazette, about seven years ago, which 
had a unique history. The patient, who was much improved by gal- 
vanism, had shown symptoms of the affection from a very early age. 
He was a twin boy, and his brother did not develop the affection. 

PARALYSIS FROM SPINAL CURVATURE— See Spinal Cur- 
vature and Caries. 

PARAMETRITIS— See under Pelvic Cellulitis (page 591). 

PARAPHIMOSIS. 

The surgeon grasping the penis behind the glaus between the middle 
and index-fingers of his interlocked hands, pulls the foreskin forward, 
while at the same time he presses back with both thumbs the swollen 
glans until it slips behind the constriction. This is the usual method. 
The writer prefers to grasp the penis behind the glans, between the 
index and middle fingers of the left hand, near to the metacarpopha- 
langeal joint, while with the index finger and thumb of the right hand, 
or with the last joints of all the fingers of the right hand, he surrounds 
the swollen glans, and steadily reduces the swelling by patient continu- 
ous pressure until its bulk becomes greatly reduced, when it generally 
slips through the constricting band, sometimes painlessly. The success 
of the ordinary method is chiefly due to the forcible traction of the 
prepuce forward, and in the latter method to the reduction of the glans 
through the strictured ring almost by the same gentle manipulation as 
in a hernia. The glans may be reduced in size by winding a rubber 
band around it, but the steady pressure of the fingers is better. 

Where these means fail, which should be seldom, except in cases of 
neglect, there is no use in waiting to apply ice, but after chloroform 
the taxis may be again tried, and if reduction is not possible, the sur- 
geon looks for the site of constriction, and divides it with a sharp- 
pointed curved bistoury, taking care to make his vertical incision close 
to the glans behind the collar of swollen preputial tissue and not in 
front of it, as the appearance of the parts might suggest. The glans 
should be forcibly depressed by the tip of the left thumb as the incision 
is being made, and as the narrow preputial orifice is divided, reduction 
is easily accomplished. 

PARAPLEGIA— See under Myelitis (page 513). 

PARONYCHIA— See Onychia (page 553). 

PAROTITIS— See Mumps (page 512). 

PEDICULI. 

The destruction of these parasites often gives considerable trouble, 
and to effectually banish them some knowledge of their habits is essen- 



PEDI-CULI. 589 

tial. Thus, the ordinary body louse is seldom seen upon the skin, and 
as it resides in the seams and creases of the clothing, it cannot be de- 
stroyed until the garments are subjected to the action of heat or re- 
agents which kill the parasite. It must also be kept in mind that 
agents which are destructive to the pediculi may have no effect upon 
their ova ; and since these are not hatched until after the expiration 
of nine or ten days, the case cannot be regarded as cured until after 
this period has elapsed. After the total destruction of the parasites 
and their ova it may be sometimes necessary to treat the eczema or 
other lesions to which their presence has given origin. 

Pediculi capitis. In mild cases which have not been long neglected 
there is no uecessity to cut or shave the hair, but in hospital this must 
often be done, and when once thoroughly accomplished there is no 
trouble afterward, as the ova are also removed adhering to the hair. 
Shaving is, however, almost impossible, owing to the numerous crusts 
and scabs. Close clipping by sharp scissors answers every purpose, 
and a good washing with soft soap completes the destruction of any 
straggling vermin or adhering ova. 

In ordinary cases a remedy should be prescribed which, though 
capable of destroying the pediculi rapidly, should not be of such a 
nature as to injure the patient, even if injudiciously applied. This is 
a matter of vital' importance in large charity or other schools, where 
mercurial preparations should not be used. The favorite old-fashioned 
remedy is a safe one, viz., the ointment of stavesacre (B. P.), which is 
made to contain 10 per cent, of the oil. This, when rubbed into the 
roots of the hair or used as a pomade, effectually destroys the lice, but 
does not reach the ova contained in the nits. If the application be 
continued for a fortnight every trace of the vermin is removed, the 
young pediculi being killed as they are hatched. 

Where there are many crusts a soft linseed-meal poultice, smeared 
over with carbolic oil (1 : 15), speedily destroys the mature parasites, 
or a few minutes under the carbolic spray is still more efficacious. 

For large numbers of children, especially in female industrial schools 
and similar institutions, there is not any remedy equal to paraffin or 
common petroleum oil, mixed in the proportion of 1 part to 1 or 2 of 
olive oil. When this is used as an ordinary hair-oil these vermin are 
never seen, and by using it the writer has found that the pediculus 
corporis soon disappears from the children's clothing. He has known 
the undiluted paraffine oil to be extensively used as an ordinary hair 
oil for long periods without causing any irritation whatever. 

In cases where a rapid effect is desired and where skilled nurses are 
entrusted with the management of children, as in a children's hospital, 
a weak solution of bichloride of mercury may be employed. But one 
of the best of all applications is the ointment of the ammoniated mer- 
cury, or white precipitate (1 : 10), as it not only destroys the parasite, 
but effectually relieves the eczema or impetigo which has resulted from 



590 PEDICULI. 

the scratching and irritation caused by its presence. When there is 
much secondary skin affection present, petroleum should be used with 
caution. 

For the treatment of the nits or egg-cases, the hair may be well 
soaked in strong alcohol after washing with soft soap, or vinegar or 
solution of borax may be applied ; and after they have become loos- 
ened from their moorings by these solvents, a very fine comb easily 
clears the hair of them. 

Many other agents are employed, such as naphthol, solutions of 
tobacco and cocculus indicus, chloroform, dalmatian flowers, pepper- 
mint, cajaput, anise or clove oils, decoction of laurel leaves, quassia, 
pellitory, creolin, etc. They possess no advantages over the more com- 
monly used remedies. 

Shoemaker adopts the excellent plan of incorporating the paraciticide 
with soap, and his corrosive sublimate and naphthol soaps are elegant 
and effective remedies for these pests. 

The objectionable odor of paraffin may be overcome by making it 
into an ointment or pomade with lard or vaseline, and adding some 
balsam of Peru. 

Pediculi corporis are to be abolished by cleanliness. As they live 
and deposit their ova iu the seams of the clothing, the most effective 
method of dealing with them is to place the clothing for a few hours 
in a hot chamber or disinfecting-room, so as to thoroughly bake the 
pediculi and their eggs. Boiling the clothes answers equally well. In 
treating school children for itch by sponging their bodies over with the 
solution of peutasulphide of calcium (see 5th edition of Materia Medica 
and Therapeutics, page 517), the writer found that pediculi also disap- 
peared when the clothes were immediately put on again. The white 
precipitate ointment may be smeared over the shoulders and armpits ; 
and if it does not speedily cure the accompanying eczema or prurigo, 
other measures, such as alkaline baths, and inunctions of olive oil, may 
be prescribed. 

Pediculi pubis or crab lice may prove very difficult to eradicate, 
especially when the parasite affects the various regions of the body in 
hairy men. When confined to the pubes a few applications of strong 
carbolic lotion (1 : 20) may destroy them, but the eggs are not likely 
to be affected by this. The writer has seen them effectually abolished 
by painting the parts once with the glycerin of carbolic acid (1 : 4), 
but this is a severe remedp, and only applicable where the parasite is 
limited to a small area. Solution of corrosive sublimate (2 grains to 1 
ounce) may be freely applied where the beard, whiskers, eyebrows, or 
chest are effected. The most manageable application, however, is an 
ointment of white precipitate (25 or 30 grains to 1 ounce of lard). 
This may be frequently smeared over the affected regions without any 
danger of salivation, and if a little paraffin oil be added a most effica- 
cious parasiticide may be obtained. 



PELVIC ABSCESS — PELVIC CELLULITIS. 591 

Be . — Hydrarg. ammon gr. xxxv. 

Oleipetrolei 3yss. 

Bals. Peruviani 3J. 

Lanolini ad gviij.— M. 

A 5 per cent, calomel ointment is also generally efficacious, and 
Bernbeck advises a bath of 4 drachms of corrosive sublimate in 30 
gallons of water as a remedy for all pediculi. Of all the mercurial 
preparations the speediest and at the same time the safest is that of 
Brocq. He uses a solution of 1 grain of corrosive sublimate dissolved 
in 1 ounce of vinegar, and states that this kills both the parasites and 
their ova at the same time. 

The common practice of rubbing in the strong mercurial ointment 
over extensive regions of skin is objectionable and dangerous. 

Iodoform ointment, or even the application of iodoform gauze, is 
often effective. 

Chloroform destroys both the parasite and ova by one thorough 
application, but it is liable to cause serious cutaneous inflammation or 
irritation. 

Ether spray is equally efficacious, and very much less irritating, and 
it may be applied over any large tract, as over the front of the chest 
and pubes, without danger. 

PELVIC ABSCESS. 

The treatment will be in the early stages the same as for any deep- 
seated inflammation or abscess (see under Abscesses.) Thus, rest, 
opium, leeching, hot fomentations, poultices, enemata or occasional 
salines, are indicated. In the later stages, when suppuration has 
occurred, the treatment applicable to the later stages of pelvic cellulitis 
(which see under the following heading) should be carried out. 

PELVIC CELLULITIS OR PARAMETRITIS. 

If seen in the earliest stage of an acute attack, the patient should be 
at once ordered to bed, and if a rigor or shivering fit ushers in the attack 
the usual remedies necessary to restore reaction should be employed, 
such as a little warm stimulant internally and hot water bottles to the 
feet ; but at this stage a diagnosis is scarcely possible unless the affection 
supervenes upon some pelvic irritation which had previously suggested 
the possibility of parametritis supervening. As the symptoms and 
signs of the affection develop they are to be dealt with upon general 
principles. Thus absolute rest in the horizontal position is to be main- 
tained. The diet is to be exclusively milk, or liquids such as might be 
permitted in fever. The bowels should be cleared out by an enema 
of tepid water, and an occasional saline purgative may be safely admin- 
istered. 

Hot water injections may be freely resorted to from the very begin- 



592 PELVIC CELLULITIS. 

ning. The water should be as hot as can be borne, and two or three 
gallons may be used at a time, the temperature being gradually 
increased until 108° F. can be tolerated with comparative comfort. If 
the injection of hot water aggravates the patient's pain or discomfort it 
must be stopped. Any harm, however, likely to arise from this method 
of treatment will probably consist in the temperature of the water 
being too low. Less than 100° at the beginning of the injection 
should not be tried, and even 110° may be reached and maintained 
with safety. 

Hot fomentations, poultices, lotions, or compresses may be applied 
over the abdomen during the intervals between the syringing. The 
best application will be a large piece of spongio-piline squeezed out of 
very hot water, and sprinkled with laudanum, and bound moderately 
tightly by means of a calico binder. This can be worn continuously, 
and will not be interfered with by the syringing, which must be car- 
ried out as the patient lies upon her back in bed. As a rule, the warm 
applications having been commenced are to be kept up constantly 
until the termination of the inflammatory action. 

Pain is to be subdued by small doses of opium often repeated. It 
is a good plan to begin with a pill containing 2 grains of powdered 
opium, and to keep up the effect by given J. grain every two, three, or 
four hours, according to the severity of the symptoms. Any simple 
diuretic combination may be given if the skin keeps dry and hot, or 
the opium may be prescribed in the form of Dover's powder. 

Antipyretics proper are not indicated in the very early stages, but 
any time that the temperature runs up to 104° or more, 10 or 15 grains 
of antipyrine may be administered, and repeated when necessary. 

Leeching is the only form of blood-letting admissible, and many 
authorities recommend a dozen or more leeches to be applied over the 
skin above the groins, about the anus, perineum, or even to the vagina 
or cervix. The writer has never seen a case where such practice was 
likely td do good. 

Quinine is clearly indicated in septic cases, and 4 grains with I 
grain of the watery extract of opium may be given every three or 
four hours. Iron may be useful in such cases if it agrees with the 
state of the digestive organs. 

Mercury is liable to be given too freely in pelvic cellulitis. It is of 
most unquestionable value in the opinion of the writer, but salivation 
is to be deplored. It is never necessary to touch the gums, nor does it 
appear to be good practice to exhibit the drug until after the appear- 
ance of the dense solid exudation has been evident for some time. 
When given in small doses it hastens resolution. From a limited ex- 
perience, which does not, however, justify the writer in drawing a gen- 
eral conclusion, he is led to suspect that the drug, if given too early, 
is liable to favor suppuration, but if withheld until the fluid part of 
the exudation has become absorbed, it gives a better chance of satis- 



PELVIC CELLULITIS. 593 

factory resolution, and it gives best results when combined with quinine 
and opium, as in the following : 

li . — Hydrarg. chloridi mit gr. ss. 

Quininse sulphatis gr. ijss. 

Ext. opii . .' gr. ss. — M. 

Make twenty-four of these. 
S. — Take one three times a day. 

Iodide of potassium is very useful at a still later stage, and it may 
be given safely in doses of 10 to 15 grains where smaller doses cannot 
be tolerated. 

Complications must be met as they arise. Thus vomiting will be 
best relieved by ice and a simple saline or effervescing mixture con- 
taining a little hydrocyanic acid, while smart counter-irritation by a 
large sinapism applied over the abdomen is also useful. 

Diarrhoea should not be checked, especially if the motions are very 
decidedly offensive. The writer has observed this in several cases 
where pus had formed, and he is inclined to regard it as a valuable 
sign of the absorption or infection of the system when rigors fail to 
warn. It is an indication for large doses of quinine and stimulants, 
and for the suspension of mercury or iodides, and the continuation of 
poultices and hot vaginal douches tinged with a little Condy's fluid. 

Sleeplessness is best met by sulphonal, and not by increased doses of 
the opiate. In chronic cases resolution may be hastened by counter- 
irritation with strong liniment of iodine or small blisters, and at a 
very late stage, long after the subsidence of all inflammatory action, 
by massage and the use of the -continuous current (50 to 80 or 100 
milliamperes), with one pole in the vagina and the other over the 
pubes. 

When, in spite of the above measures, the inflammatory exudation 
softens and suppuration occurs, the case becomes one of pelvic abscess, 
poulticing must be continued, and the diet increased to the fullest ex- 
tent of the digestive powers of the patient, strong soups and beef 
essences being freely administered. Pointing must be watched for 
anxiously. Speaking generally, one may say that at this stage the less 
interference or the fewer examinations the better. The mischief 
which may be wrought by the sound or the speculum should be kept 
in mind. In the vast majority of cases, the slower the process by 
which the matter travels in the direction of the least resistance the 
safer for the patient. Doran insists upon the danger of aspiration. 
The writer has never seen it used at this critical time without some 
mischief ensuing, except when a fine needle has been inserted for 
diagnostic purposes. All the skill, discretion, and experience of the 
surgeon will be required in deciding whether the abscess should be 
opened or left to nature. The probability is, that if a mistake be 
made it will be by interfering. Where the abscess points toward the 



594 PELVIC CELLULITIS. 

surface there can be little if any danger in waiting, and if opened too 
early, owing to the rigid state of its infiltrated walls, it does not 
readily collapse, and air easily enters. Hence, when opened, which 
should not be under ordinary circumstances until almost ready to 
burst through the skin, a free incision should be made under anti- 
septic precautions, and a drainage-tube inserted. Afterward the cavity 
should be gently washed out daily with warm solution of boric acid, 
very weak bichloride of mercury solution, or Condy's fluid, but irri- 
tating substances like iodine or chlorinated liquids are not to be em- 
ployed. A large pad of iodoform gauze may be placed over the 
opening, or, if the discharge is very free, carbolic tow or teased oakum 
may be selected. 

When the matter bulges into the floor of the pelvis, and is felt in 
the rectum or vagina, the question of making an opening or leaving 
the case to nature is to be speedily decided. Aspiration is out of the 
question. One of two courses may be determined upon, if interference 
is necessary at all — viz., either to plunge in a bistoury and evacuate 
the abscess at the most prominent part in the vagina or rectum, or else 
to thrust in a large curved trochar and canula, driving the canula 
home after the trochar has been removed, as described under the treat- 
ment of Hematocele. In either case the largest sized drainage-tube 
should be inserted through the opening made by the bistoury or through 
the canula, when in position, before being withdrawn. Through the 
drainage-tube (a large winged rubber catheter may be employed) the 
abscess cavity may be frequently washed out by a -warm solution of 
boric acid or other mild unirritating antiseptic once or twice daily. 

If the surgeon can satisfy himself that the abscess is not bulging to- 
ward the peritoneal cavity, but is pointing in the one safe direction — 
i. e., toward the vagina or rectum — interference is a mistake ; but it is 
not often that one can satisfy himself upon this point, and where there 
are reasons to suspect that to wait for the discharge of the abscess 
through the vaginal wall would be to incur the risk of its bursting 
into the peritoneal cavity, incision should be made at once. 

When the evidence is clear that the abscess has burst into the peri- 
toneum there still may remain much to be done, as a fatal issue is 
almost certain if the case be left alone, and it will become then a ques- 
tion of the advisability of performing abdominal section. Unquestion- 
ably life has been saved by opening the abdomen under such circum- 
stances. 

The horizontal position and rest are to be maintained for several 
weeks after apparent recovery. Where drainage is being carried out 
the patient may be placed in such a position as to ensure the most 
complete evacuation of all discharges. 

In the stage of convalescence, tonics, change of air, iron, cod-liver 
oil, syrup of the phosphates, with peptonized foods and malt extracts, 
are useful. 



PELVIC PERITONITIS — PEMPHIGUS. 595 

PELVIC HEMATOCELE— See Hematocele, Pelvic, page 304. 

PELVIC PERITONITIS. 

The treatment of this affection will be best carried out by adhering 
to the principles just laid down for the management of pelvic cel- 
lulitis. 

In both conditions preventive treatment should play a most import- 
ant part, and the conscientious accoucheur who adheres to a system of 
cleauliness, carried out with the greatest scrupulosity, will see much 
fewer cases of this class than will fall to the lot of him who fails to 
recognize the enormous amount of mischief which may follow a careless 
or slovenly style of obstetric or gynecological practice. 

Absolute rest, opium, warm fomentations, or poultices and leeching 
may be indicated. Where hot applications are not tolerated Leiter's 
tubes, cold compresses, or ice may be tried. Fever may be present to 
an extent sufficient to jeopardize the patient's chances of life, and anti- 
pyretics may be necessary from the very commencement. Upon the 
w T hole, where the digestive organs are in good condition, and when the 
temperature is not very high, the safest and most efficacious treatment 
will be to administer quinine in combination with the tincture of chlo- 
ride of iron ; 5 grains may be given dissolved in 20 minims of the 
tincture diluted with 2 ounce of water. This acts well in cases where 
there are obvious septic causes at work. Where the temperature 
rapidly mounts to a great height, as in cases of puerperal fever, as a 
rule quinine is not to be depended upon, but large doses of antipyrine 
(20 grains), antifebrin (10 grains), or salicylate of sodium (30 grains) 
may be given at intervals. Where suppuration occurs the abscess is 
most likely to point toward the vagina, and the same rules are to guide 
the surgeon as if a case of suppurating pelvic cellulitis was under 
treatment. (See Pelvic Cellulitis.) 

Saline purgatives, which are so beneficial in some cases of cellulitis, 
are to be used with more caution in peritonitis, and when an action of 
the bowel is required an enema of tepid water may be employed. The 
practice of locking up the bowels for two or three weeks is certainly to 
be condemned in ordinary cases. In all cases of this nature, when a 
purgative must be given by the mouth, there can hardly be a difference 
of opinion about the safest drug. Castor oil in small doses never does 
any harm. 

PEMPHIGUS. 

In a disease presenting such widely differing symptoms and signs as 
pemphigus, the treatment will necessarily vary very much at different 
stages of the affection. For the acute disease, rest in bed, and a liquid 
or milk diet, may be indicated. In the chronic or the foliaceous form, 
upon the other hand, the chief treatment will consist in the adminis- 
tration of the most nutritious foods and in the greatest amounts prac- 



596 PEMPHIGUS. 

ticable. As in many other diseased conditions in which we feel at a 
loss for indications for treatment, through our ignorance of the 
pathology or etiology it is customary to advise that every other depart- 
ure from health is to be sought for and remedied as far as possible • by 
improved hygienic surroundings, altered diet, drugs, change of habits, 
scene, etc. 

Of the drugs for the treatment of pemphigus there is one which, 
though it sometimes fails utterly, nevertheless in many cases it appears 
to exert a specific influence, and it should always be administered freely 
and for a considerable period. Arsenic should be prescribed as soon as 
the temperature becomes normal in acute cases, and at all stages of the 
chronic varieties of the disease. It is, however, of little use in the 
foliaceous form. The dose of 3 minims of Fowler's solution should be 
rapidly increased to 6, and afterward to 9 minims three or four times 
a day, immediately after meals ; and though some patients may be met 
with in whom 15 minim doses may be tolerated for long periods, it is a 
good practice not to venture beyond three doses of 10 minims each in 
the twenty-four hours. It is needless to say that it should be well 
diluted before administration. Ill chronic cases the arsenic should be 
combined with iron. Cod-liver oil and quinine are also both of some 
value in the foliaceous form of the disease. The cod-liver oil may be 
given in tablespoonful doses of the Kepler extract preparation, imme- 
diately before or after a mixture containing 7 or 8 minims of Fowler's 
solution and twice as much tincture of iron. 

Where arsenic, after an honest trial, fails, chlorate of potassium in 
large doses may get a good trial ; it has succeeded in some cases. 
Anderson, however, recommends the hypodermic injection of arsenic 
when it fails by the mouth, and he even combines quinine with it. 

Iodide of sodium in full doses (5 to 15 grains) may also get a trial. 
Belladanna, guaiacum, phosphorus, antimony, and even mercurials 
have been recommended, but unless when arsenic has completely 
failed in the foliaceous form their administration is not worth a trial. 

In pemphigus vegitans, Pollock and Hutchinson advise an early 
resort to opium in full doses. This variety is always fatal. 

Local treatment will depend upon the stage of the affection. In 
acute cases, characterized by great tension in the bullae, these may be 
pricked with a suture-needle or lancet and dressed with zinc ointment 
or any bland unirritating salve. Powders freely dusted over the 
weeping surface are in some cases better, especially when excoriations 
are present. Among dry applications of this sort are finely-powdered 
Fuller's earth, oxide of zinc, chalk, starch, prepared calcamine, oleate 
of zinc, etc., either alone or mixed in such proportions as the appear- 
ance of the parts indicates. 

Unna's paste is a convenient and grateful preparation. It may be 
prescribed by ordering : 



PERFORATING ULCER QF THE FOOT. 597 

K= . — Cretne prnep. 

Zinci oxidi _ . 

„,.... I aa 5i.— M. 

Olei lim OJ 

Aquas calcis 
S. — To be used as directed. 

Lotions are sometimes preferable to either ointments or powders, 
and Secretan has most successfully treated pemphigus pruriginosus by 
continuous applications of compresses soaked in a 1 per cent, solution 
of carbolic acid. This effectually relieves itching and hastens healing. 

The writer has used the ordinary carron oil, to which 1 or 2 per cent, 
of carbolic acid is added, for chronic cases. Cripps reports success 
from the application of oleate of mercury. 

In very tedious cases of the foliaceous variety the physician will feel 
his resources taxed, and the best plan is to permit the patient to lie in 
the tepid bath for several hours daily, after which the excoriations may 
be dressed with zinc ointment, to which 5 or 10 grains of calomel per 
ounce may be added. Two or 3 drachms of corrosive sublimate may be 
added to 30 gallons of water as a mercurial bath, but the patient 
should not rest in this for any considerable length of time. 

Baths are fitted up in which the patient can eat and sleep, and 
Kaposi has found these of the greatest benefit in very chronic cases 
associated with much prurigo or itching. Bran, gelatin, carbolic acid, 
or tar may be added to them. In one very obstinate case of foliaceous 
pemphigus the writer obtained considerable benefit by the use of the 
continuous current, but the patient left hospital before the treatment 
was completed. 

Where the mucous membrane of the mouth is affected, the constant 
use of the glycerin of borax (1 : 6), gargles of chlorate of potassium, 
or tablets of the chlorate with borax, are the best local applications. 

PERFORATING ULCER OP THE FOOT. 

The treatment of this affection is at the best unsatisfactory and 
tedious, as it is always associated with some nerve lesion, like tabes 
dorsalis. The cause should receive careful attention, and complete and 
permanent healing of the ulcer may be expected in a percentage of 
cases. The advice given by surgeons who are apt to recommend ampu- 
tation of the foot should not be seriously entertained until the failure 
of medical treatment has been demonstrated. In one case which the 
writer saw with Dr. Wales, permanent healing occurred after the use 
of the continuous current. This was applied in various ways for 
several months, chiefly by dropping one pole into a foot-bath of tepid 
water, while the other pole was applied to the sciatic region, or held in 
the hand. 

The remedies suitable to the treatment of the primary lesion should 
be steadily persevered in at the same time, and the anaesthesia soon 



598 PEEICAED.IUM, DROPSY OF. 

begins to get less and less. In tabes dorsalis, chloride of gold, arsenic, 
iodide of sodium, antipyrine, and suspension should have a fair trial, 
but it is upon electricity that dependence is to be placed. The ulcer 
may be dressed by any stimulating ointment, as the unguentum dia- 
chylon, or by very weak nitric acid, bichloride of mercury solution, or 
spirit lotion, by means of a piece of lint covered with tinfoil or thin 
sheet lead. 

When diseased bone is present, it should be removed by the gouge 
or forceps, and if the wound is very sluggish it may be occasionally 
brushed over with a strong solution of nitrate of silver or touched with 
strongest nitric acid, or acid nitrate of mercury solution, or even 
brought into light contact with the therm o-cautery, or scraped thor- 
oughly with a Volkmann's spoon. When all these measures fail, a 
Syme's or a Teale's amputation may then be seriously considered. 

PERFORATION OP STOMACH AND BOWELS— See under 
Gastric Ulcer, Typhoid Fever, Perforative Peritonitis. 

PERICARDIUM, Dropsy of. 

In the majority of cases this will yield to active treatment, directed 
against the cause of the hydropericardium. Thus, if it be part of the 
general anasarca of Bright's disease, the best measures will be diapho- 
retics (hot baths), diuretics (digitalis), and cathartics (sulphate of mag- 
nesia). Where the fluid remains stationary or continues to increase, 
there is nothing left but to tap or aspirate the pericardial sac. 

This is not an operation to be undertaken without an accurate knowl- 
edge of the anatomical structures in the front of the thoracic cavity. 
Unless previous tapping has failed, the practice of making an incision 
with a sharp bistoury into the pericardium is not to be thought of. 

After mapping out the area of dulness, and ascertaining, as far as 
possible, the limits of the heart, as the patient lies upon his back with 
his shoulders raised, a fine hypodermic needle may be inserted, and 
some fluid withdrawn, in order to verify the diagnosis. 

The needle puncture may be made almost anywhere, but it is better 
to make it in the same spot into which the aspirator, trochar, or needle 
is to be afterward inserted. This spot is of importance, it must be near 
to the sternum, and the left is the side generally selected. Some sur- 
geons go close to the sternal margin, others advise keeping one inch, 
and some recommend the puncture to be made two inches from the 
margin of the bone, in order to avoid the internal mammary artery. 
The fourth or fifth interspace is the best, though the sixth or seventh 
may be selected in some cases. 

The operation may be successfully performed by perforating the 
fourth or fifth space upon the right side, though upon the whole, it 
would appear that the left fifth interspace close to the sternum is the 
best, though either side may be selected. 

The needle should be inserted upward so as to avoid the heart, and 



PERICARDITIS. 599 

the fluid must be very slowly withdrawn. It is a good plan to detach 
the aspirator, and keep the end of the tube under a little carbolic lotion, 
while by a syphon action the cavity is slowly emptied. An ordinary 
hydrocele trochar and canula has been used, but the aspirator needle 
is better. The needle should be kept steady while the fluid is being 
withdrawn, though it does not appear that pricking of the ventricular 
walls is of necessity a serious mishap. Wheelhouse inserts the trochar 
on the upper surface of the fourth rib to the left of the sternum, and 
advancing it steadily upward from left to right, until the cardiac im- 
pulse could be felt, withdraws it, leaving the canula in position. 

Should the fluid be found to be purulent, the tapping will probably 
require repetition, and though the treatment in this case should be 
detailed under the head of pericarditis, it may be mentioned here for 
convenience. Drainage in this case will be essential. The passage of 
a fine drainage-tube through the canula would meet all the require- 
ments of the case, but this will generally be found impracticable, owing 
to the narrowness of the canula, hence, an opening must be made with 
a sharp scalpel or bistoury. The best site for the incision will be that 
of the previous punctures. 

t The incision should be made as recommended by Cheron, the tissues 
being incised layer by layer for a distance of three or four centimetres 
(rather more than one inch) taking care to avoid the internal mammary 
artery, which may, if necessary, be drawn upward. The exposed peri- 
cardium may then be caught up in forceps and opened by means of a 
guarded bistoury. Antiseptic precautions should be taken both in the 
tapping as well as in the cutting operation. The greatest care must be 
exercised should irrigation be deemed necessary, though such a proce- 
dure is not desirable, and irritating antiseptics must not be employed. 
If considered absolutely necessary, a little warmed boric acid or per- 
manganate of potassium solution may be used. 

PERICARDITIS. 

The diseased condition which has led to the inflammation of the peri- 
cardium will demand treatment, and in many cases this is all that is 
necessary, and as the affection is commonly a complication of or sequel 
to acute rheumatism, the reader will find the anti-rheumatic treatment 
under the heading of Rheumatism. The special treatment will be 
almost identical with that of endocarditis, which see upon page 239. 
The following is a brief enumeration of the remedies indicated : Abso- 
lute rest in the horizontal position, poulticing, leeching, blisters, or 
milder counter-irritation, opium to relieve pain, digitalis at a later 
stage (5 minim doses) to strengthen the heart, and at a still later stage 
small doses of mercury are useful. When pericarditis occurs as a com- 
plication of pleuritis or pneumonia, in addition to the employment of 
the above agents, the remedies indicated for these diseases must be 
pushed. Where it occurs in connection with septic conditions or ulcer- 
ative endocarditis, active supporting measures must be resorted to as 



600 PEEIHEPATITIS — PEEINEUM, EUPTUEE OF. 

extra feeding, stimulants, sulphocarbolates in large doses (25 to 30 
grains), quinine to the extent of inducing cinchonism, and iron in full 
doses. 

Where the amount of fluid is so large as to threaten life the peri- 
cardium may be tapped with a fine aspirator needle, and when sup- 
puration has occurred, provided the primary lesion is not necessarily 
a fatal one, life may be saved by opening and draining the pericar- 
dial sac. Both these operations are described upon the previous pages 
under the heading of Pericardium, Dropsy of. 

PERIHEPATITIS. 

Is generally an accompaniment of peritonitis, of hepatitis, or cir- 
rhosis, or even of cancer of the liver, and its treatment will consist 
in the exhibition of the remedies suited to these different affections, 
while pain is relieved by opium or morphine internally, and poultices, 
blisters, counter-irritants, leeches, or local anodynes externally. 

PERINEPHRITIS. 

Pain must be relieved by hot linseed poultices, warm fomentations, 
or mild counter-irritants, and some still believe that the free applica- 
tion of the liniment of iodine, if applied early, may prevent suppu- 
ration. 

Of internal remedies, tonics, such as quinine and large doses of iron 
may be prescribed, but these cannot be expected to do more than 
improve the general health, and no law can be laid down except that 
remedies are to be used to combat symptoms as they arise. 

Boric acid in 10 grain doses may be given where calculous pyelitis 
is the primary lesion, and this is often the case. 

As matter forms, a free incision should be made with a sharp bistoury 
over the softest spot in the lumbar region posteriorly, skin, fascia, and 
muscles being divided under strict antiseptic precautions, and a large 
drainage-tube should be inserted after the evacuation of all pus and 
sloughs. 

PERINEUM, Fistula of— See under Urinary Fistula. 
PERINEUM, Rupture of 

The prevention of this complication at delivery is detailed under 
the head of Labor. When the rupture occurs, if only of small extent, 
it may be safely left to nature, the most rigid cleanliness being observed 
afterward by frequent sponging of the parts with a warm antiseptic 
solution as weak Condy's fluid or carbolic lotion. 

Where the laceration has extended through a considerable portion 
of the perineum, as already mentioned, after cleansing the torn sur- 
faces, one> two, or more deep sutures should be inserted with a large 
curved needle, and the margins of the wound brought into accurate 



PERIOSTITIS. 601 

position. This operation to be successful, should be performed imme- 
diately after the birth of the child, and the bowels should not be dis- 
turbed for three or four days, after which a warm water enema may 
be given. When the rupture has involved the rectum, the bowels 
should not be disturbed for three or four days, after which a warm 
water enema may be given. When the rupture has involved the rec- 
tum, the bowels should not be disturbed for six or seven days, and the 
vagina should be washed out two or three times a day with warm 
water injections, deeply stained with Condy's fluid. Herman strongly 
advises the use of catgut sutures. 

In rupture of long standing, various plastic operations are recom- 
mended, the edges of the rent being pared and brought together by 
sutures. The modifications of this operation are very numerous, and 
are outside the scope of the present work. 

Tait's operation is the best. It is based upon the principle of 
removing no tissue, so that if failure should occur the patient is not 
left in a worst position. It is rapid, and gives excellent results. 
The recto-vaginal septum is split horizontally by curved, sharp-pointed 
scissors, and the edges of the perineal rent are also split up vertically 
by scissors, the edges being brought together by sutures, without trans- 
fixing the skin edges of the flaps. 

Duke inserts the left index-finger deeply into the rectum, and with 
a long, straight, double-edged bistoury he pierces the tissues in front of 
the anus, guiding the knife as the septum is penetrated upwards for 
two and a half inches, the incision being enlarged laterally to two 
inches at least, as the knife is withdrawn. Sutures of silver wire are 
inserted by a needle bearing an eye in its point. 

PERIOSTITIS. 

Absolute rest of the affected limb, which should be elevated upon a 
pillow as the patient lies in bed, and in very mild cases following 
trivial injury, where the inflammatory action is circumscribed, the 
application of spirit lotion under oiled silk is all that is necessary to 
effect resolution. Where acute periostitis follows severe injury, or 
appears as a complication of syphilis or of any of the exanthemata 
occurring in weak patients, active treatment will be necessary to 
relieve pain and prevent the extension of the disease. Warm poul- 
tices or hot fomentations applied to the affected limb, if they afford 
relief, should be persisted in. If they fail, leeches should be applied, 
and bleeding encouraged by fomenting the bites afterwards. Should 
these measures fail to afford relief, one or two small incisions may be 
made through the periosteum down to the bone. This plan effectually 
prevents the injurious effects of prolonged high tension, and thus 
minimizes the after ill effects of the inflammation, and may prevent 
necrosis. 

In severe cases it is a mistake to wait for signs of fluctuation when 
pain and tension are excessive. Strict antiseptic precautions should 

39 



602 PERIOSTITIS. 

be taken, and if pus is present the same treatment may be adopted, 
but the incision should be a bold and free one, and the knife should 
be felt to reach the hard bone beneath the inflamed periosteum. 

After the incision, antiseptic poulticing should be continued. This 
may be simply carried out by dressing the wound with carbolic lotion 
(1 : 40), applied on lint, and covered with oiled silk, upon the top of 
which large deep pads of cotton wool may be secured by a light 



Constitutional treatment will depend upon the severity of the case 
and the symptoms present. Where there is much fever, a simple 
diaphoretic, preceded by a brisk saline cathartic, .as 1 ounce of 
Rochelle salt, is a good plan. Where syphilis exists, large doses of 
the iodide of potassium are most efficacious in relieving pain and 
cutting short the disease, and the older surgeons still employ calomel 
and opium in every case. The iodide often relieves the dull nocturnal 
pains in cases which are not specific, and there is generally no reason 
why it cannot have a trial in every case. The following is a good com- 
bination in the early stages. At a later stage the aconite may be 
omitted : 



. — Potassii iodidi .... 


. gr. lxxx. 


Tinct. aconiti .... 


. . . . ITlxx. 


Liq. ammon. acet. 


.... iij. 


Syr. aurantii .... 


• 3Jss- 


Aqufe canaph. . . 


. ad 3x.— M 



S. — Take a tablespoonful after meals, three times a day, and at bed-time. 

Where the temperature runs high, large doses of the iodide, as a 
rule, are not well borne, and then a mixture containing 5 grains of 
antipyrine may be given every four hours. It often relieves the pain 
markedly. In the later stages iron and quinine and extra diet are 
essential. 

In the very severe cases where the periosteal inflammation invades 
the entire length of a long bone, the serious symptoms which supervene 
rapidly may terminate fatally in a short time, unless prompt measures 
be taken to relieve the local and alleviate the constitutional disturb- 
ance. The first step in the treatment, as soon as the diagnosis war- 
rants, is to make a series of deep and free incisions parallel with the 
shaft of the affected bone. These should pass through all the tissues 
and periosteum down to the bone, and may even be extended into the 
bone (linear osteotomy) by inserting a Hay's saw into the wound. 
This operation, which some surgeons recommend in chronic cases, may 
be followed by great reduction in the tension, but the incision should 
not be extended as deep as the medullary canal, and should not be 
made in the very early stage. 

By these means acute diffused periostitis may be prevented from 
running into acute necrosis, and the shaft of the bone may be saved 



PERITONITIS, ACUTE. 603 

aud the patient's life rescued. The constitutional treatment will con- 
sist in absolute rest, a highly nutritious liquid diet, and large doses of 
quinine or cinchona preparations, with alcoholic stimulants. After 
the making of the incisions, warm antiseptic poultices should be ap- 
plied every few hours, and as the progress of the case indicates the 
formation of new collections of pus, further incisions from time to time 
may be required. Where the death of the shaft occurs in spite of free 
and early incisions, and it becomes separated from its epiphyses, 
Clutton advises its removal by means of sub-periosteal resection 
before the formation of new bone. 

Under Necrosis the subsequent management of those cases which 
have terminated in the formation of sequestra is detailed. 

Chronic periostitis is generally syphilitic. It is to be treated upon 
the same general principles — rest, counter-irritants, and mercury with 
iodide of potassium in very large doses, and incisions when these 
measures fail. The writer has seen excellent results follow trephining 
in a chronic case which had resisted all measures. It is not unusual 
to come across patients suffering from chronic and painful periostitis 
or nodes, who have been taking mercury or iodides in a desultory way 
for years without benefit. Such cases generally yield rapidly to large 
doses of the iodide (20 to 30 or 40 grains), and full doses of mercury 
just short of salivation act like a charm after a course of the iodide. 

Ostitis is to be treated upon the same lines in the early stage as 
periostitis — rest, leeching, poultices or fomentations, blisters and 
counter-irritants, and large doses of iodide of potassium. Where 
these fail, and the pain continues to wear out the patient, free inci- 
sions may be made with a stout scalpel through everything down to 
the bone, after which linear osteotomy may be performed by cutting 
through the shaft with a Hay's saw until the medullary canal is 
reached. 

Where the pain is confined to a small circumscribed area, a piece of 
bone may be removed by trephining. 

Syphilitic cases yield generally to 30 grain doses of iodide of 
potassium, and after the relief of the more urgent symptoms of pain 
and tension, a mercurial course must be commenced and steadily 
maintained. 

PERITONITIS, Acute. 

It is difficult to give any concise account of the treatment of a con- 
dition so varied as that which is known under the term peritonitis. 
At the bedside it is well for the student to discard the term altogether, 
and to only think of the disease as a symptom of another affection. This 
may not be strictly correct advice, as there may be such a thing as 
idiopathic peritonitis, but it is so rare that, given any ordinary case 
of inflammation of the peritoneum, it may with safety be regarded as 
secondary to inflammation of some other organ within the abdomen, 
to tubercle, septic poisoning, typhoid fever, perforation or rupture of a 



604 PERITONITIS, ACUTE, 

hollow viscus, hernia, impactions, intussusceptions, injuries, hemor- 
rhages, aneurisms, etc., or to inflammations or abscesses arising within 
the chest and extending through the diaphragm. (The writer has 
detailed and figured a rupture of the thoracic duct which produced 
a most interesting peritonitis. (See British Medical Journal, May, 
1885,) 

Thus it is obvious that the first step in the treatment of peritonitis 
is to find out the primary cause, and employ such measures and reme- 
dies as in the present state of our knowledge are best suited to the 
management of the primary lesion. These will be detailed under the 
different headings scattered through the present volume. It is lament- 
able to find a physician who, approaching a case with the idea that he 
has to overcome an idiopathic affection, continues to give opium and 
other anti-peritonitic remedies until a strangulated hernia is allowed to 
cut short a valuable life. 

In the absence of such organic lesions as must be still regarded as 
beyond the reach of a cutting operation (and these are few), and where 
the cause is obscure, an attempt should be made to modify the inflam- 
matory action by such measures as experience has proved to be often 
successful. 

Rest is essential. The patient instinctively learns this himself, and 
lies in bed upon his back with the knees drawn up ; but in mild cases, 
or in those treacherous varieties of peritonitis where little pain is expe- 
rienced, the most absolute rest must be rigidly enforced. It may be 
necessary to protect the abdomen from the weight of the bedclothes by 
a cradle or other appliance. 

Next in importance to rest is diet. Nature also dictates this in the 
majority of cases by causing the stomach to reject all solid nutriment, 
but often the patient may be tempted to partake of food which may 
lead to fatal results unless clearly warned by the physician. There is, 
perhaps, no other condition demanding greater care and judgment in 
the selection of food. As a rule, liquid nourishment alone is admis- 
sible ; it should be given in very small quantities, and often. Less 
than a wineglassful of iced milk may be given every two hours mixed 
with a little lime-water or effervescing potash water, or half this amount 
may be given every hour. 

In the case of children smaller quantities are necessary, and, as 
thirst is sometimes prominent, this rule will require enforcement. It is 
a matter of some moment that only the requisite amount of fluid should 
be handed to the patient on each occasion. A skilled nurse will not 
put to the lips of a thirsty and feverish patient more liquid than he is 
permitted to swallow at once. With young children it is a good plan 
to feed them with a spoon. Where milk cannot be tolerated, small 
quantities of beef-tea or beef-essence may be given, and ice in propor- 
tion to thirst and nausea. Ice is often abused, and strict directions 
should be given for its administration. The object of the physician is 
to administer only as much food as is necessary, and in such a way as to 



PERITONITIS, ACUTE. 605 

prevent vomiting. Once this is started, it may be no easy matter to 
control it. If ice be swallowed in any quantity it melts in the stomach, 
and accumulates until vomiting is set up. Hence only small pieces 
should be given, and not too often, the object being that ice or milk in 
small quantities may be tempted to pass through the stomach before 
the arrival of the next dose. 

Where vomiting is a prominent symptom, feeding by the stomach 
may be abandoned, and the rectum may then be washed out and made 
ready for nutrient enemata. A mixture of strong beef-tea and milk 
thickened with a little flour or gruel, and not exceeding 4 fluidounces, 
should be warmed, and just before use a dessertspoonful of Benger's 
liquor pancreaticus should be added. This may be gently thrown into 
the rectum every three or four hours. 

At a later stage, in the absence of vomiting, other liquids may be 
permitted by the mouth, such as rennet, chicken soup, thin arrowroot, 
or other farinaceous foods. It is advisable to lay down the law that 
in the early stages of convalescence from peritonitis only such foods, 
or mixtures of foods, are admissible as will pass through the meshes 
of a fine sieve. Sifting is unnecessary, but this statement gives the 
nurse and "patient's friends a clear idea of what is to be avoided — 
i. e., the administration of anything containing even fine solid par- 
ticles. In the later stages the amount of liquid nourishment needs no 
restriction. 

Alcoholic stimulants may be required where collapse is present at 
the beginning, and in protracted cases, where debility and exhaustion 
are prominent features at the end of an attack. Champagne or good 
sparkling Hock may be useful in allaying nausea or preventing vomit- 
ing. Occasionally whiskey by the rectum may be necessary, when 
everything is rejected by the stomach. 

Opium comes next in importance to rest and feeding. It is the one 
drug upon which reliance is to be placed, and it may in some cases be 
given in very large quantities. As a rule, the amount of pain present 
may be taken as a safe guide to the amount required. If the physician 
is satisfied that absorption is taking place, he may fearlessly administer 
opiates in desperate cases, regardless of any preconceived notions about 
dosage, taking as his guide the effect upon the pain present. To reck- 
lessly pour down opium, especially in the form of pills, without waiting 
to see by the symptoms of the case whether it is being absorbed, 
should be censured. The doses may accumulate, or the pills may pass 
through the stomach, and be all absorbed at once, and give rise to 
serious symptoms. A knowledge of the rate of absorption, and a little 
reflection upon the altered state of the digestive organs, will prevent 
this. 

When there is no vomiting, and the pain is very severe, 45 or even 
60 minims of tincture of opium may be given in a serious case ; but it 
will be wiser to give two doses of 30 minims each, with an interval of 
one, two, three, or more hours between. The effect is to be kept up by 



606 PERITONITIS, ACUTE. 

smaller doses at short intervals. The pilular form is, upon the whole, 
the best, owing to the risk of the liquid preparations being expelled by 
vomiting ; but it is well to begin with the liquid, and keep up the 
effects by pills. Where pain continues to be excruciating, and the physi- 
cian gets timorous about the absoption of the anodyne, he may give 
one dose by the mouth, another soon after by the rectum, and another 
hypodermically. In this way he need not fear accumulation. When 
prescribing opium in the pilular form in such cases it is a wise plan to 
prescribe some simple combination, in order to insure the pills being 
made up fresh. 

One grain of opium in a pill has been prescribed by the writer, and 
pills had been dispensed which had evidently been made many months 
previously, and which would have furnished tolerably effective ammu- 
nition for rabbit shooting. He has known such to remain more than 
twenty-four hours in a healthy intestinal canal before the physiological 
effects of the drug commenced to show themselves. By writing a re- 
ceipt for the following, which are not likely to be kept ready made, 
these objections are overcome : 

&. — Pulv. opii gr. j. 

Ext. belladonnas alcohol. gr. i- 

Bismuthi oxidi gr. j. — M. 

Make 24 such pills. 

S. — Take one four times a day. 

Where vomiting is incessant the writer prefers the modern elegant 
perule or pearl containing i or T X g- grain of morphine. Unlike the pill 
of crude or powdered opium, it does not appear to become insoluble ; 
and as it is not larger than a millet-seed, it can be placed upon the 
tongue, and is almost beyond the risk of being ejected by vomiting. 
The weaker strengths are the best for general use, as any number may 
be easily administered at once. In renal disease and in very young 
children, opium must be used with the greatest care. 

Mercury is still a favorite in the hands of some, and is supposed to 
exert an important influence over the inflammatory action. This is 
doubted by many, and the practice of salivating for peritonitis is for- 
tunately a relict of the past, though calomel is often given in small 
doses in combination with opium. The experience of the writer has 
convinced him that in the early stages of acute peritonitis mercury is 
worse than useless. He had the opportunity some years ago of seeing 
the effects of small, oft- repeated doses, which appeared to seriously de- 
press the patients and diminish their chances of recovery. In the later 
stages of the disease, however, when the violence of the inflammatory 
action has subsided, calomel in small doses is of the greatest service. 
Under its influence the tongue grows clean, and lymph and effused 
products rapidly become absorbed, and the bowels are probably brought 
sooner into a more natural condition. 



PEKITONITIS, ACUTE. 607 

Bloodletting is likewise becoming a practice of the past, and will 
doubtless become entirely so as the rarity of true idiopathic peritonitis 
is more generally recognized. 

Leeching may be still resorted to in sthenic cases, and by its early 
use may relieve pain and tension, especially in cases where the inflam- 
matory mischief is local, as in perityphlitis. A dozen leeches may be 
applied, and the writer has known fifty to be used in a case of general 
peritonitis. Where blood is to be extracted to this extent it would 
seem, however, much more rational to open a large vein and make a 
rapid impression upon the general circulation. 

Saline purgatives have been much vaunted in acute peritonitis of 
late years, and numerous cases have been reported where very satis- 
factory results have followed their administration in the hands of sur- 
geons. Meigs has ably explained this by showing that in surgical 
practice acute peritonitis is often anticipated after abdominal opera- 
tions ; and large doses of salines, administered at the very onset of the 
attack, may check the inflammatory action by directly depleting the 
abdominal and intestinal bloodvessels, through the production of large 
watery evacuations. The physician, as a rule does not meet with 
peritonitis in these very early stages. 

When the disease has become established it is probable that the in- 
creased peristalsis would be a dangerous evil by interfering with the 
rest which is essential to the recovery of the inflamed intestinal peri- 
toneum. 

It is by quieting peristalsis and reducing the intestinal movements 
to a minimum that opium becomes of such very great value ; and with 
our present knoweledge it is almost certain that the routine adminis- 
tration of purgatives would in many cases inevitably lead to fatal re- 
sults, especially in cases of obstruction. Nevertheless, sometimes — 
especially when the intestinal tube is known to be patent — salines may 
be of great value, but their exhibition must be always a most critical 
experiment. Their introduction has, however, drawn attention to the 
fact that the dread of purgatives has led to the opposite extreme of 
locking up the bowels for long periods, to the detriment of the patient. 
From the result of several post-mortem examinations, the writer is in- 
clined to believe that many patients die from want of a purgative, but 
this number would likely be a very small percentage of those who 
would succumb if the administration of purgatives became the rule 
and the use of opium the exception. 

Where it is found necessary to increase peristalsis with the view of 
overcoming an obstruction in the bowel, a fair dose of castor oil is most 
decidedly the safest of all purgatives, but it is not the most efficacious. 
It may move the bowels and leave large impactions untouched, and it 
is, moreover, often rejected by the stomach. 

Calomel in one large dose is then most efficacious, and 6 or 8 grains 
may be placed upon the tongue and allowed to find its way down into 
the stomach. Before its administration the physician must give the 



608 PEKITONITIS, ACUTE. 

most serious consideration to the symptoms and general condition of 
the patient. 

Enemata of tepid water may at the same time be steadily persevered 
with. They should be given slowly and deliberately, and should con- 
tain no soap or irritant, the object being to get up as much fluid as 
possible without exciting peristalsis, while the patient lies upon his 
back with the pelvis raised. The use of the long tube, passed far up 
into the bowel, is, in the writer's opinion, a delusion, and much more 
likely to do harm than good. Meigs, who lays great stress upon the 
skill and judgment necessary in determining the exact moment at 
which a purgative should be administered in acute peritonitis, does not 
recommend either castor oil or salines, but advises the physician to feel 
his way with the following combination, which may be given every 
four hours unless violent pain is set up 



R . — Ext. belladonnse . 

Ext. nucis vomicae 

Pulv. ext. aloes 

Pulv. rhei rad. 
Make twelve of such pills. 
S.— Take one every four hours. 



gr- tV 
gr. h 
gr. h 

gr. f .— M. 



The local treatment of peritonitis is of some importance. As a rule, 
pain and distention are relieved by warm poultices applied every two, 
three, or four hours. At first, counter-irritation by means of mustard 
may be practised until the skin is well reddened, after which the con- 
tinuous application of linseed-meal poultices may be proceeded with. 
Dr. Wales carries out this plan by means of a simple contrivance. A 
piece of thin flannel is laid upon a table, dry mustard is rubbed into 
this over an area as large as the required poultice, which is then spread 
upon the top of it, another piece of flannel is laid over the face of the 
linseed ; there is thus obtained a poultice between two layers of flannel. 
The side containing the mustard is placed next the skin until smart 
counter irritation is produced, when the poultice is simply reversed, 
the side corresponding to the plain linseed being then placed in contact 
with the skin and allowed to remain as long as the poultice keeps warm. 
A large piece of spongio-piline, wrung out of hot water, makes a good 
substitute for a poultice. 

Cold applications sometimes afford more relief than poultices, and 
when this is the case, they may be safely used during the early stages. 
Leiter's tubes, cold compresses, bladders of ice, or iced cloths may be 
applied. 

Various anodynes, as laudanum, belladonna, aconite, etc., may be 
tried alone or smeared over the face of the poultice. As a rule, they 
are little worth. Turpentine is a favorite counter-irritant used in the 
form of hot fomentation. Strong iodine or blisters may be indicated 



PERITONITIS, CHRONIC. 609 

at a later stage, when mercury internally is also beneficial, when it is 
desired to cause absorption of effused products. 

When tympanitis becomes very distressing, a very fine trocar and 
canula or hollow needle may be used to puncture the intestine in sev- 
eral regions, with the object of permitting the escape of imprisoned 
air. 

When peritonitis fails to yield to the above measures, and the diag- 
nosis of an organic cause becomes certain, there is no use in further 
delay. Abdominal section, followed by irrigation and free drainage, 
may be the only chance of saving life. 

Meigs states : " When called to attend a patient suffering with peri- 
tonitis we should first determine the cause, and if it is found to be an 
organic one the immediate use of the knife, followed by irrigation and 
drainage, is the only proper method of procedure. Should the cause 
be found to be functional, the use of purgatives, followed, if necessary, 
by enemata, is indicated ; and these failing to relieve quickly, surgical 
methods should soon follow." The writer thinks this is too strongly 
put. (See the question considered at greater length under Intestinal 
Obstruction, page 419.) 

Even in cases of acute suppurative peritonitis in the female following 
gonorrhoea, abdominal section with removal of the tubes, and even of 
the ovaries, flushing the abdominal cavity out with hot distilled water, 
and inserting a large drainage-tube, is a successful operation. It may 
be said that in nearly all cases of suppurative peritonitis the washing 
out of the peritoneum should be resorted to, in order to give the patient 
a chance for life, unless, under special circumstances, the condition can 
scarcely be made worse by such a procedure. 

PERITONITIS, Chronic. 

The treatment of the chronic affection is to be carried out upon the 
same lines as that of the acute affection, the chief point being to find 
out the cause and treat it. As a general rule, it may be said that the 
chief indication is to effect the absorption of lymph and effused fluid. 
Pain may require anodynes, but these should be used sparingly. 
Poultices, when pain is severe, may be employed, as in the acute 
variety, though counter-irritation is more likely to accomplish the 
desired end. Iodine is the best application. It may be tried in two 
different ways : the weak tincture may be painted on over the entire 
abdominal surface once or twice daily, either alone or mixed with a 
little weak spirit and glycerin, with the view of its becoming absorbed 
and finding its way into the lymphatics, or the strong liniment of 
iodine (1 : 8) may be brushed on daily as a smart counter-irritant until 
the skin begins to crack. The writer has obtained excellent results 
from the lin. potas. iod. cum sapone (B. P.) gently rubbed over the 
abdominal surface once a day and covered by a tightly fitting flannel 
bandage. 



610 PERITONITIS, PERFORATIVE 

In strumous cases, the invaluable plan for the continuous applica- 
tion of cod-liver oil under a mackintosh binder has already been fully 
described (see page 507). This method is of the greatest possible 
benefit in some cases of chronic peritonitis. 

Blisters may be useful. A series of small circular or square blisters 
may be applied over different parts of the abdomen for short periods 
(two or three hours), as in the treatment of pleuritis by flying blisters. 
In this way fibrino-serous fluid may be got rid of without resorting to 
surgical measures. At a later stage massage of the abdomen may be 
tried. 

Internal treatment may be of use, and the selection of remedies must 
depend upon the primary cause of the peritonitis and upon the special 
or prominent symptoms present. As a rule, it may be said that cod- 
liver oil, iron, and iodides afford the best prospect of success. 

Diuretics, purgatives, diaphoretics, and hot baths, with the view of 
causing removal of effused fluid, are usually worthless, though diu- 
retin has been recently praised. Mercurials are seldom indicated. 
When they are, the best method of employing them is to smear a 
little diluted mercurial ointment over the cod-liver oil bandage under 
the mackintosh, and then apply moderate pressure by an outside calico 
binder. 

When these measures fail to remove fluid, paracentesis may be re- 
sorted to. (See under Ascites.) Sometimes the primary affection may 
demand abdominal section, and the removal of chronically inflamed 
organs or uterine appendages, or the breaking down of adhesions. 

Constitutional treatment in all cases is of the greatest importance. 
Nutritious food, pure air, change of scene, sea bathing, tonics, malt 
extracts, and peptonized preparations, are indicated in very chronic 
cases, 

Constipation, tympanitis, vomiting, diarrhoea, and other complica- 
tions are to be met by appropriate measures. 

PERITONITIS, Perforative. 

Absolute rest, ice to the abdomen, and the cessation of all feeding 
by the mouth, with opium in large quantities, have been formerly held 
to be the only available means of meeting this terrible condition, 
which, as a rule, ended fatally. 

Now, such cases are regarded as instances of suppurative peritonitis, 
and treated often with complete success by making an abdominal in- 
cision, removing the contents of the stomach or intestines out of the 
peritoneal cavity, washing it by repeated and copious flushings of hot 
water until the fluid returns perfectly clear and odorless. The perfo- 
ration should be closed by suture, and thorough drainage established. 
Some surgeons use very weak corrosive sublimate, boric acid, carbolic 
or salicylic solutions. 

In this way, perforating ulcers of the stomach and intestines have 
been successfully dealt with, and several cases have been recorded 



PERITONITIS, TUBERCULAR. 611 

where the vermiform appendage has been the seat of perforation, and 
where incision of the abdomen has been carried out, and the appendix 
ligatured, the cavity thoroughly irrigated, and drainage established 
with complete success. 

Abdominal incision in perforation of the bowel occurring in typhoid 
fever has been most unsatisfactory. Success is not to be expected in 
cases in which the perforation occurs while the fever is high or the dis- 
ease in its active stage. 

PERITONITIS, Tubercular. 

The treatment of acute tubercular affection of the peritoneum will 
consist in the exhibition of those remedies which give some relief in 
acute tuberculosis, as large doses of quinine or antipyrine, to reduce 
the high fever generally present, together with the measures which ex- 
perience has proved useful in the treatment of acute peritonitis as rest, 
poultices or warm fomentations, opium, liquid diet, ice, etc. The ques- 
tion of abdominal section in acute cases need hardly be discussed, 
because the diagnosis is uncertain in the early stages, and as the dis- 
ease may be general, operative measures would be contra-indicated, 
and lastly, acute tubercular peritonitis is not often associated with 
purulent secretion in the abdominal cavity. Suppose, however, a case 
of acute tuberculosis limited to the peritoneum, and running into or 
causing suppurative peritonitis, could such a case be diagnosed with 
anything like certainty abdominal section and free washing out of the 
peritoneal cavity, with the establishing of free drainage, would be jus- 
tifiable ; and, notwithstanding the generally -accepted notions about 
the incurability of tuberculosis, such treatment might have been long 
since proved to be ultimately successful, after Spencer Wells' case, in 
which the patient was alive and well twenty -two years after the opera- 
tion. (See below.) 

The treatment of chronic tubercular peritonitis, formerly regarded 
as incurable, affords one of the most striking and brilliant examples 
of the success of modern abdominal surgery, and is almost certain to 
lead to far-reaching results in the management of tubercular affections 
generally. 

For the relief of symptoms and general medical treatment little need 
be said, beyond reminding the reader that the management of a case 
of this disease will consist in the judicious exhibition of those remedial 
agents indicated in the treatment of chronic tuberculosis, along with 
the administration of remedies suitable for the relief of the accompa- 
nying peritonitis. The relief of pain, constipation, diarrhoea, hectic 
fever, and the prevention of debility and emaciation until the patient 
can be placed in a position in which there is some hope of his throw- 
ing off the tubercular disease by change to a more suitable climate, 
constituted the routine treatment until lately universally adopted. 
The great value of the cod- liver oil inunction, and its continuous ap- 



612 PEKITYPHLITIS AND TYPHLITIS. 

plication by means of the binder and mackintosh, have already been 
referred to. 

Abdominal section has been performed in some hundreds of cases with 
a success which could hardly have been anticipated. The abdomen has 
been incised, washed out thoroughly with warm water or weak antiseptic 
liquid, and drainage established where this was necessary. Ascites, as 
a rule, never occurs again, and hence, future tapping is unnecessary. 
Tait has had uniform success, as far as the operation was concerned, 
and a complete cure of the disease in 80 per cent, of all cases of 
tubercular peritonitis in which the abdomen was opened, cleaned, and 
drained. 

The statements of Konig are hardly less surprising and inexplicable. 
He has collected 131 cases of peritoneal tuberculosis treated by ab- 
dominal section, of which 23 were greatly improved, 84 were cured 
(65 per cent.) ; of these, 30 exhibited no signs of intra-peritoneal 
tuberculosis for several years following abdominal section. In only 3 
per cent, could death be attributed to the operation. A recent able 
writer reviewing these results, points out that as to the methods by 
which these cures were obtained, examination of the cases shows that 
there was only one condition common to all, that is, that the belly was 
freely opened and a certain amount of intra-peritoneal manipulation 
was practised. Even the free use of anti-bacterial agents appears in 
no way to improve the results. 

PERITYPHLITIS AND TYPHLITIS. 

The treatment of inflammation of the veriform appendix will be 
best conducted upon the same lines as that of acute peritonitis. 
Absolute rest in bed, lying upon the back with the legs drawn up so as 
to relax to the fullest extent the abdominal muscles, is the position to 
be enforced unless already instinctively selected by the patient. Hot 
fomentations or poultices should be applied at short intervals. Some- 
times leeching gives great relief. Liquid nourishment in small quan- 
tities and often, especially beef tea or meat essences, and opium in full 
doses in proportion to the pain and constitutional disturbance, as in 
peritonitis, should be taken. 

With this treatment in full operation, the physician closely watches 
events, avoiding the use of purgatives, and treating vomiting and other 
complications by appropriate remedies as they arise. Many, perhaps 
the majority of cases yield to these measures without further inter- 
ference, and the bowel gradually begins to act in response to copious 
warm water enemata. 

When signs and symptoms indicate the formation of matter the case 
assumes a serious aspect, but the physician should wait before hastily 
concluding that the abdomen requires opening, and watch events for a 
little longer. 

The situation of the pus is of the utmost importance. If it be clear 



PERITYPHLITIS AND TYPHLITIS. 613 

that it is extra-peritoneal, hot poulticing will tend to hasten its approach 
to the surface, when a free incision will generally remove all immediate 
danger. Where the local signs point to a probable collection of pus, 
and the constitutional symptoms are running high, a hypodermic needle 
may be deeply inserted, and by injecting a few drops of weak carbolic 
solution the needle is cleared of all blood, and as the action of the 
piston is reversed, a few drops of pus may be obtained. In this case 
no harm can come of making a free, deep incision through skin, fascia, 
and muscle, down to the sac of the abscess, which should be washed 
out and a large drainage-tube inserted. In this operation the general 
cavity of the peritoneum is unopened. 

It must, however, be kept prominently in mind that the so-called 
cases of perityphlitis do not often arise from accumulations or perfora- 
tions occurring in the caecum. The appendix vermiformis is the starting 
point in the great majority of cases, and accumulations, concretions, 
perforation, and gangrene of this troublesome appendage are, of course, 
much more liable to lead to dangerous and fatal peritoneal mischief, 
which can only be averted by prompt abdominal incision. 

The situation then becomes most serious, and the physician whose 
faith in opium and rest is unlimited may allow the patient to pass 
beyond the reach of surgery before a laparotomy be decided upon. 

The abdomen may be opened in advanced cases with fair prospects 
of recovery even after a general suppurative peritonitis has followed 
the perforation of the appendix, or the bursting of an abscess into the 
cavity. The mistake in these cases is generally made by the physician, 
who delays with drugs instead of calling in the assistance of the 
surgeon. Where there is no evidence of a general suppurative peri- 
tonitis, the best operation is that of opening the abdomen through the 
right linea semilunaris. This is advised by Langton, as it enables the 
surgeon to open the peritoneal cavity in the region of the iliac fossa 
without being too near to the appendix where adhesions are very liable 
to exist, and he prefers it to Gaston's operation in the linea alba. 

It may, however, be a wiser plan to select the free median incision 
where there will be the probable necessity of flushing out the abdominal 
cavity with a weak warm antiseptic solution. In Langton's case re- 
ported in the Medico- Chirurgical Transactions for 1889, he found the 
appendix vermiformis gangrenous to the extent of two-thirds of its 
length with a solid concretion of feces at the line of demarcation. The 
appendix was ligatured, and the gangrenous portion removed, the 
abdominal cavity being well washed out with several quarts of sanitas 
water at a temperature of 100° F., a drainage-tube being inserted and 
iodoform dressings applied. Seventeen days afterward some suppura- 
tive peritonitis declared itself in the opposite side of the abdomen. The 
patient was again placed upon the table, and the abdominal cavity 
opened in the middle line, the peritoneum well washed out with warm 
water, and a Keith's drainage-tube inserted after the removal of a 
quantity of extremely fetid pus from the left iliac fossa. A rapid and 



614 PERITYPHLITIS AND TYPHLITIS. 

uninterrupted recovery followed. This brief sketch of a case where 
recovery followed two abdominal operations should convince the phy- 
sician that where there is reason to suspect a perforation in the ap- 
pendix, or a diffuse general suppurative peritonitis, the patient should 
not be denied the excellent chance which an abdominal section affords. 

Few subjects have attracted more attention, of late years than the 
treatment of inflammation of the appendix, and the view of early 
abdominal incision is rapidly gaining ground, especially as reports of 
successful operations are being published every week, where the condi- 
tions discovered upon opening the abdomen have been demonstrated 
to be incompatible with recovery. 

Weir, in referring to the name perityphlitic abscess l>y which the 
condition is generally known, points out that all such abscesses originate 
in the peritoneal cavity, and there grow considerably before invading 
extra-peritoneal tissues, and that their cause is perforation of or a gan- 
grenous condition of the appendix vermiformis, which as soon as a 
tumor can be felt should be opened by a lateral incision into the peri- 
toneal cavity. He further insists that where no tumor can be felt, if 
the symptoms point to an increase of the local peritonitis and vomiting 
with increased abdominal resistance and higher temperature continuing 
for forty-eight hours, the danger of the disease is greater than that to 
be feared from the lateral or median abdominal operation which should 
then be immediately resorted to. 

McBurney, who first pointed out the most important diagnostic point 
in connection with appendicitis, i. e., the invariable presence of a 
minute point of exquisite tenderness almost exactly two inches from 
the anterior iliac spine on a line drawn from this process through the 
umbilicus, thus describes the preliminary steps of the operation : " The 
incision should be a liberal one, for much room may be required, and 
a five-inch cut in the adult is not too much. It should follow as nearly 
as possible the right edge of the rectus muscle, and the centre of the 
incision should lie opposite to or a little below the anterior iliac spine, 
on a line drawn to the umbilicus. When the external oblique aponeu- 
rosis is cut through by this incision the aponeurotic structure in which 
the other abdominal muscles end comes into view, and is easily divided 
without cutting muscular fibre. Then the fascia transversalis, the sub- 
peritoneal fat, and the peritoneum are cut in succession. On opening 
the peritoneum the appendix may at once be seen, or adhesions and 
inflammatory exudation may have so distorted the parts that a careful 
and difficult search may be required to find the appendix at all." The 
subsequent steps of the operation will vary in every case as no two are 
alike, but the appendix should, if possible, be separated from surround- 
ing structures, tied with silk or catgut close to the csecum and cut 
away. The stump will then require careful scraping and disinfection, 
and the entire neighborhood must be well treated with bichloride solu- 
tion, a drain inserted, and the small space packed with iodoform gauze. 

Some surgeons, after the operation, resort to saline purgatives to 



PERSPIRATION, EXCESSIVE. 615 

prevent further peritoneal inflammation, and to avoid the adhesions 
which are liable to occur during the period of paralysis of the bowel. 

The same serious consideration must be given to the exhibition of 
purgatives during the later stages, as has been already referred to under 
Acute Peritonitis. The physician may, however, resort to warm water 
enemata first, and afterward to a small dose of castor oil. The old 
method of giving large quantities of metallic mercury to cause mechan- 
ical evacuation of the bowel is very dangerous and unjustifiable. In 
the convalescent stage, laxatives, tonics, good feeding, and change of 
air, with other restoratives, will be indicated. 

PERSPIRATION, Excessive. 

Under Phthisis, the various remedies for the profuse perspiration 
which accompanies the septic stages of that disease will be discussed. 
In the great majority of other cases where excessive perspiration is 
present it will be found to be secondary to some other affection which 
requires treatment, as chronic alcoholism, acute rheumatism, ague, etc. 

In those comparatively rare cases where hyper-secretion of the sweat- 
glands occurs, independent of any other affection, some abnormal con- 
dition of the vasomotor nerve supply is probably present and may 
require treatment. The clothing should be light and absorbent, thin 
flannels being the best fabric for wear next the skin. 

The skin should be bathed in very hot water to which vinegar is 
added in cases where there is no elevation of cutaneous temperature, 
and smart friction is afterward to be employed. Unna then advises 
an ointment containing ichthyol and turpentine to be rubbed in before 
bed-time. This is to be washed off in the morning, very cold water is 
to be used and thorough friction, after which a powder containing 
mustard is to be dusted over the skin. In cases where the skin is warm 
he advises the use of the ichthyol ointment or soap. 

Some authorities recommend the inunction of the entire body with 
sweet or neat's-foot oil. Of internal methods of treatment, the writer 
believes that a very dry diet with the least amount of fluids will give 
the best results. 

Atropine, -giro to y-J-g- grain, three times a day, alone, or with 15 to 
30 minims of the fluid extract of ergot, may be tried. Sulphuric acid, 
tannin, quinine, strychnine, agaric, minute doses of pilocarpine, 
sulphate or oxide of zinc, and nearly every remedy found useful in 
diminishing the night sweating of phthisis have been used, but their 
effects are very transient. 

A 5 grain tabloid of sulphonal, twice or three times a day, is a very 
good remedy where the perspiration is general. 

Arsenic and iron in combination with nux vomica may be tried, and 
the continuous current is sometimes useful. 

It is, however, generally in cases of local hyperidrosis, accompanied 
by an unpleasant odor in the perspiration, that the physician is con- 



: 



616 PERSPIKATION, EXCESSIVE. 

suited. This affects most commonly the feet and toes or the armpits 
and groins. In feet cases the affection is sometimes so severe as to 
make the victim a nuisance to others, aud relief is most desirable. 
The internal remedial agents may be tried, but the writer seldom 
employs them at all, as local treatment will give excellent results in 
the great majority of cases when the patient can be got to carry it out 
thoroughly. 

This affection, which is dignified by the name of osmidrosis or 
bromidrosis, can only be removed by the most absolute cleanliness. 
The stockings or socks should be changed at least once a day, and 
in bad cases oftener. The writer advises these, after washing in warm 
and cold water, to be dipped in a strong or saturated solution of boric 
acid, and allowed to dry. This makes a boric gauze. They should be 
manufactured from very thin fine-spun wool or a mixture of wool and 
cotton. The feet being bathed morning and night in tepid or cold 
water, and briskly rubbed with a coarse towel, which should be care- 
fully passed between the toes, should then be thoroughly dusted over 
with the finely powdered boric acid, and the stockings drawn gently 
over them. This plan will often enable the owners of tender, per- 
spiring feet to pass the summer walking exercises in comfort. 

In the German army a weak solution of chromic acid is used for 
this purpose. The writer gave this method a fair trial, but abandoned 
it in favor of the safer and more efficacious boric acid. The boric acid 
may also be used in the form of an ointment (1 part to 3 of lard), and 
this may be freely smeared over the feet. It is better than the powder 
for the armpits, but it destroys the clothing. 

Hebra employed daily for several weeks a firm diachylon ointment, 
consisting of equal parts of linseed oil and lead plaster, or of the 
formula on page 81, spread upon pieces of linen sufficient to cover 
each foot, smaller pieces being placed between the toes. A bandage 
being applied, the stockings and boots were afterward worn over the 
ointment. 

Salicylic acid, oleate or oxide of zinc, talc, Fuller's earth, naphthol, 
bismuth, rice powder, and other powders are used. 

Bardet uses the powder mentioned upon page 81, after washing 
with alcohol, or else the following : Rice powder, 60 ; subnitrate of 
bismuth, 25 ; permanganate of potassium, 10; talc, 5. 

Shoemaker uses powdered oleate of zinc 3 parts, and powdered 
starch 4 parts, or equal parts of salicylic acid and subnitrate of 
bismuth, or naphthol 1 part, and powdered boric acid 12 parts. 

Antiseptic ointments of all kinds, as well as lotions containing cor- 
rosive sublimate, carbolic acid, creasote, tannin, lead, zinc, alum, and 
other astringents, are also recommended ; but the writer prefers the 
boric acid to all other methods. (See also under Bromidrosis, page 
80.) 



PERTUSSIS. 617 

PERTUSSIS. 

As sood as an attack of severe whooping-cough is declared, the 
physician may lay his plans for a long siege, in which he may feel 
confident that if the little patient's strength be maintained, and the 
various possible complications warded off, the enemy is bound to 
capitulate at the end of six or eight weeks. Remedies administered 
with the view of cutting short the attack at the beginning fail, and the 
treatment should from the first be directed to those measures which 
will place the patient in the best position for withstanding the long 
drain upon his strength. 

Isolation is the first question to be settled. This is to be decided 
upon the peculiar nature of the patient's surroundings, and, as it 
generally will be required for eight or ten weeks under ordinary 
circumstances, there is no use in beginning a system of isolation in a 
half-hearted way, nor is there any use of insisting upon it where it is 
almost certain to break down in a few weeks. Moreover, no plan of 
isolation should be accepted which will confine the patient to one 
room during the entire illness. As a rule, in this country the patient's 
parents, who generally know a good deal beforehand about such a 
common disease, refuse to carry out a system of rigid isolation. The 
writer's practice is to warn the patient's relatives of the danger which 
might arise if some weakly member of the family were to catch the 
contagion, and to urge upon them the advisability of placing several 
rooms in the house at the disposal of the invalid, and advise that the 
others should be sent away. 

The child should have large, well-ventilated sleeping and play 
rooms, especially in the winter-time, and at all times when possible. 
This is a matter of more importance than nurses, and parents can be 
made to see. As will be mentioned later on, disinfection being neces- 
sary during, as well as at, the termination of the illness, everything 
capable of being injured by the fumes of burning sulphur should be 
removed. 

The next point to be settled is the one of permitting the child to 
go out-doors. Moderately strong children, even in smart attacks, not 
only are safe, but are much better for being out all through the attack. 
Plenty of fresh air is really of more importance than medicine in a 
long illness like whooping-cough. Of course, in severe weather, with 
rain and cold, or during the prevalence of the spring east winds, or in 
the presence of any bronchial complications, out-door exercise must 
be forbidden. 

Diet is of great importance, and, in the management of weakly 
young children, will turn the scale for or against recovery. The 
usual diet which experience has proved to agree best with the child is 
to be continued, provided it be wholesome and highly nutritious. A 
mixed and varied diet does best with grown-up children. 

After the paroxysms have become thoroughly established and the 
appetite begins to fail, the patient must be coaxed to take milk or other 
nutritious fluid nourishment between meal-times. 

40 



618 PERTUSSIS. 

After a time, when the paroxysms are attended by v.omiting, the 
critical period in the dieting arrives. The nurse should be directed to 
withhold food for a short time in the presence of a threatening or ex- 
pected attack of coughing, and to aim at having the child fed as soon 
as possible after an attack, so as to permit the food to be as long as 
possible in the stomach before the next turn of vomiting. By carefully 
attending to this hint, lives may be saved. 

Hard, indigestible food in the stomach, as nuts, green fruits, unripe 
apples, etc., will increase the laryngeal spasm, and portions of un- 
chewed beef and potatoes may give serious trouble during the act of 
vomiting. Hence, upon the whole, a liquid diet is to be preferred for 
small children, or the ingredients should be carefully comminuted. 

Clothing should be warm, and so arranged as to prevent overheating 
at one time and chills at another, an even temperature and the avoid- 
ance of draughts being desirable. Light flannel underclothing is essen- 
tial, except in very warm summer weather. 

During the paroxysms young children should be lifted on to the 
nurse's knee or lap, and every constriction about the neck or chest 
should be removed. Naegele states that the paroxysms may be arrested 
by simply pulling the lower jaw downward and forward, and this is 
effective also during sleep. 

As regards drugs, the list is a long and tedious one to discuss. Most 
physicians find themselves after a time settling down to the routine 
employment of one or two simple expectorant agents. Active or heroic 
medication is to be condemned. Since the improvements in our knowl- 
edge of bacilli and the part played by them in various infectious dis- 
eases, many germicides have been tried in the treatment of whooping- 
cough, but to none of these can a specific action be fairly attributed. 
The plan of treating the disease by inhalations can hardly be said to 
have proved a success, though antiseptics of a volatile and unirritating 
nature certainly appear to modify and sometimes to shorten the dura- 
tion of the disease. 

Carbolic acid in the form of a spray (1 : 100) may be inhaled by the 
patient three or four times a day, or a stronger spray be diffused fre- 
quently through the air of the room. The plan of forcing young 
children to submit to such solutions being sprayed directly into the 
mouth is not to be recommended. They often increase the frequency 
and severity of the paroxysms. 

No objection can be made to the air of the sick-room being impreg- 
nated with a volatile antiseptic like turpentine poured over the surface 
of hot water. Terebene, eucalyptus oil, peroxide of hydrogen, etc., 
may be similarly used, and they are of the greatest benefit where 
several children are confined in one room in severe weather. 

Oil of eucalyptus has been praised as an inhalation and as a spray, 
and even when given internally. Hardwicke mixes it with turpentine 
and spirit as a spray, while he gives the turpentine internally at the 
same time. 



PERTUSSIS. 619 

The following spray may be diffused through the room several times 
a day: 

R. — Olei eucalypti ,lij. 

Olei terebinthmse ^j. 

Thymol 3j. 

Spt. lavandulse ad jf vj. — M. 

S. — To be used as directed. 

Less can be said for the methods suggested for cutting short the dis- 
ease by the application of various solutions to the fauces or larynx, the 
most recent beiug that of applying a 5 to 15 per cent, solution of cocaine 
with a brush to the pharynx and larynx (some recommend this in a 
spray), and resorcin, 2 per cent., afterward. These strong solutions of 
cocaine, either when painted, swabbed over the throat, or sprayed into 
the mouth, are certainly dangerous, and if used at all with very young 
children great caution should be employed to prevent any quantity of 
the solution being swallowed. 

Resorcin spray, 2 per cent., is safer, and very glowing reports of its 
use are published. 

W. B. Richardson has recently extolled the peroxide of hydrogen as 
an inhalation and internally. 

Strong solutions of caustic or nitrate of silver are still painted over 
the fauces by some. 

Solutions of quinine, salicylic acid, nitrate of silver, corrosive subli- 
mate (1 : 10,000) have been injected into the nose, and benzoic acid or 
benzoin, quinine, iodoform, boric acid, tannin, bicarbonate of soda, 
alum, pulverized marble, have been used as insufflations. 

Bartholow uses for insufflation a powder consisting of li drachms of 
salicylate of bismuth and powdered benzoin and 18 grains of quinine. 

An ointment of 1 part of eucalyptol, 1 part of iodoform, and 16 parts 
of vaseline, is a well-known nasal application. 

Upon the whole, the reports of these methods from impartial ob- 
servers are not satisfactory, and the writer cannot speak from personal 
experience. 

As regards internal remedies, the difficulty perhaps would be in 
finding any considerable number of well-known drugs which have not 
at some time or other been pressed into the service as specifics for 
whooping-cough. Only a comparatively small number of the so-called 
specifics can be mentioned. 

Given an ordinary case of pertussis in the early or catarrhal stage, 
the diagnosis, of course, will be at first somewhat doubtful, unless other 
children are suffering from the affection in the same house. The 
writer's plan is to order a simple expectorant like the following and 
await events. For a child seven years old the following may be pre- 
scribed : 



620 



PERTUSSIS. 



R . — Vini ipecacuanhas 
Spt. ammon. aromat, 
Tinct. scillse 
Tinct. opii campli 
Syr. tolu. . 
Aquse camph. . 




!|iv.— M. 



S. — A teaspoonful to be taken four times a day in a little water. 

In mild cases of the disease this mixture may be continued all 
through, but as a rule, when the crowing begins it will be beneficial 
to substitute 3 or 4 drachms of the bromide of ammonium for the tinc- 
ture of squill. 

Such simple treatment will do something to ward off chest complica- 
tions, as the administration of ipecacuanha appears to exert some influ- 
ence in preventing further catarrhal trouble if the patient is permitted 
to run about in the open air. The medicine should be given soon after 
meals. The oxymel of squill alone may be ofteu employed, instead of 
the above mixture, with advantage. 

When the paroxysms become severe and frequent, say up to twenty 
or more in a day, and when their intensity begins to tell upon the pa- 
tient's strength, several drugs have a claim upon the physician's atten- 
tion after bromides fail. These are chloral, morphine, belladonna, 
antipyrine, conium, quinine. . The writer names them in the order 
in which they will, in his opinion, be likely to give most satisfactory 
results. 

Chloral certainly possesses marked power over the spasmodic element 
in the disease. The usual rule for dosage is 1 grain for each year of 
the child's age, but it is better to give half this amount, and more fre- 
quently, say every two hours, and even then a still smaller dose may 
do. It should, however, be always remembered that chloral is a dan- 
gerous drug in the presence of cardiac weakness, and in complicated 
cases it must be used with caution. 

Morphine also is anything but a harmless drug to administer to very 
young children, especially when there is profuse bronchial secretion. 
The physician can, however, discreetly feel his way with it. Henoch, 
whose experience is great, prefers it very much to all other narcotics, 
and he says, speaking of the remedies used in allaying the spasms of 
whooping-cough : " 1 have now come to put trust only in one, namely, 
morphine, which is far more efficacious than the much-used belladonna 
— at any rate, in relieving the violent attacks, especially those occur- 
ring during the night, and in diminishing their frequency." It may 
be used alone, in conjunction with the expectorant combination men- 
tioned upon the previous page, or along with belladonna, antipyrine, 
or chloral. With this latter drug it goes well, and when both are given 
together less of each is required, and greater safety obtained. 

Henoch's formula is the following : 



PERTUSSIS. 621 

R . — Morphinre acet. vel hydrochlor gr. i to gr. £. 

Syr. siroplicis ^ ss. 

Aqurc ad IJSS.— M. 

S. — A teaspoonful twice to four times daily. 

He does not state for what age this is suitable, but it may be given 
in the weaker strength to a child two or three years old. When 
drowsiness supervenes, the nurse should be directed to suspend the 
medicine. 

Belladonna or atropine is a favorite remedy with many for the spas- 
modic seizures, but it must not be forgotten that, to be of any practical 
use for this purpose, it must be given in doses bordering upon danger- 
ous. The physiological effect of the drug must be obtained, and, since 
this varies considerably with the dose of the different preparations, 
atropine should be selected, and its effects closely watched. A child 
three years old may receive 1 minim of the solution of atropine (1 : 100) 
every three or four hours until the pupil dilates, or 8 minims of the 
tincture of belladonna may be given instead. The extract is only to be 
used when the pilular form is selected. This is unsuitable for children, 
and there is serious danger of the powerful alcoholic extract being dis- 
pensed when the green extract is intended. 

When the physiological action of the drug has been obtained, 
smaller doses are then necessary to keep up the effect. Children bear 
the drug very well, much better than adults. The above doses may be 
given every hour for many times without producing any effects beyond 
relief to the paroxysmal attacks. Sometimes it fails completely, and 
where serious complications exist it should not be administered. The 
first evidence of delirium should warn the patient's friends or nurse to 
stop the medicine. Though this practice has had the sanction of the 
very highest authority, the writer has ceased to use it because of its 
danger and the amount of anxiety which attends the treatment of a 
case of whooping-cough by a remedy so powerful. It appears to act 
best and to require smaller doses when the disease reaches the end of 
the third week. This remedy may be safely combined with chloral or 
with morphine advantageously. 

Antipyrine has been tried with varying successes, and the reports 
are contradictory, chiefly because the first statements were so roseate, 
and subsequent observers tried the drug, expecting results which 
were not fulfilled. Nevertheless, it is clear that this agent possesses 
some influence over the severity of the paroxysms and the duration of 
the disease. It is best given alone, and a child one year old may get 
1 grain every four hours. The writer has given twice this amount to 
a child under one year. It may be given in solution in water well 
sweetened with syrup of tolu. 

The usual diaphoretics or diuretics, as spirit of nitrous ether, sal vola- 
tile, etc., should not be ordered in combination with antipyrine. It 
acts best when given in the early stages of the disease. Sonnenberger 



622 PERTUSSIS. 

recommends three or four doses in the twenty-four hours, consisting of 
as many decigrammes (H grains), as the child counts years, or as many 
centigrammes (e grain) as the child counts months. With these doses 
the cough is diminished, the paroxysms become less frequent, and the 
duration of the affection is lessened. 

Antifebrin, in proportionately smaller doses, has similar action, but 
does not appear to be so safe or uniform in its effects. 

Phenacetin has been used in the same way, but upon the whole, its 
action appears to be less uniform and satisfactory, and it does not pos- 
sess any advantages over antipyrine. The dose should be about one- 
third the dose of antipyrine. 

Heimann reports excellent results, but some other observers have 
stated that it was of no use whatever. Upon the whole, the treatment 
of this disease by means of the new analgesics is steadily losing 
ground. 

Conium has been often employed, and appears to modify the severity 
of the paroxysms when other measures have failed, but it is the least 
reliable of the remedies already mentioned, and is useless in all cases, 
unless, like belladonna, it be given in doses capable of producing its 
physiological effects. The fresh juice is the only reliable preparation, 
and of this large doses may be safely given. Ringer gave nearly 1 
ounce every hour to a choreic child. For a child three years old, 30 
minims may be given, and repeated every one or two hours until the 
physiological effects of the drug are beginning to show themselves. 
Upon the whole, the uncertainty of its action and the anxiety to the 
physician of giving a drug in such doses as cause ptosis and difficulty 
in swallowing, are not qualities to commend it, unless every other 
remedy has failed. 

Quinine is vaunted by many as almost a specific in whooping-cough. 

Its bitter taste is an almost insurmountable barrier to its internal' 
administration to children, and the writer has ceased to employ it on 
this account, except in cases where there is a high temperature, and 
where the previously mentioned remedies have failed. It has, more- 
over, another objection which appears not to have been noticed by 
those who recommend it — i. e., it tends to dry up the secretion of the 
bronchial tubes, and in this way it increases the difficulties of expec- 
toration, and hence it should be very cautiously given where there is 
much bronchial catarrh. 

Fervers recommends the hypodermic injection of the carbamide of 
quinine. Sometimes, however, the seat of injection becomes irritated, 
and an abscess forms after the use of this urea salt of quinine. 

The sulphate, muriate, or tannate may be given by the rectum in 
two full daily doses. A child three years old may get 4 or 5 grains in 
this way in the twenty- four hours if the paroxysms are very frequent 
and severe. These doses appear to diminish reflex excitability. 

Rothe uses a solution of iodized phenol for internal administration. 
The following is a modification of his formula : 



PERTUSSIS. 




. — Acid, carbolici purif. .... 


. gr. xv. 


Spt. chlorof. .... 


. . Irtlxv. 


Tinct. belladonna 


. iruxx. 


Tinct. iodi 


. . tn,i. 


Syr. et aquae 


. ad |ij.— M 



623 



Of this he gives a teaspoonful every two hours to children between 
two and twelve years. Of carbolic acid the dose seems a large one, 
and of belladonna the amount is too small to be of any use whatever. 
There is no noubt that small doses of carbolic acid are useful. One 
minim of the glycerin may be given every three hours to a child two 
or three years old. 

Rachel recommends the administration of 5 minims every two hours 
of a 2 per cent, solution of chloride of gold and sodium. 

W. B. Richardson advocates the administration of peroxide of hy- 
drogen in the form of ozonic ether, and states that he knows of nothing 
so near to a specific for whooping-cough. 

Cocaine, in small doses, has sometimes appeared to give good results. 

Alum, in doses of 2 grains for a child three years old, may be given 
every three or four hours, and is a favorite remedy with some. 

Chloride of ammonium may be given in the same way, or in combi- 
nation with alum or the bromides. 

The oxide of zinc is an old-fashioned remedy, and the writer has seen 
it do well in mild cases. A child two years old may get i grain. 

Sulphate of zinc is also used in the same way in doses bordering 
upon nauseating. 

Ouabaine, a crystalline alkaloid obtained from an arrow poison, has 
been used by Gemmell in forty-nine cases of whooping-cough in all 
stages, and he reports most favorably of its value in cutting short the 
attack if given early, or of diminishing the number of whoops if 
given in the later stages. It may be given dissolved in water, the dose 
for a child under twelve months being 20 1 00 grain every three hours. 
Double this dose, i. e., 10 1 o0 grain, may be given to a child three years 
old. 

Chloroform or ether may be occasionally employed as inhalations to 
the extent of producing mild anaesthesia where the severity and fre- 
quency of the paroxysms appear liable to end fatally by preventing 
sleep or feeding. They will be very rarely necessary, and can, of 
course, only be used at long intervals, and then only for a few min- 
utes. 

Chloroform has been used by adding a few drops (two for every year 
of the child's age) to warm water in any ordinary inhaler, and breath- 
ing the vapor four times a day. 

Nitrite of amyl is sometimes of use in such cases, and hyoscine has 
even been recommended. 

Bromoform has been recently praised by Senator and others. They 
give 2 or 3 drops thrice daily mixed in water to a child one year old, 



624 PERTUSSIS. 

and it is claimed by Lowenthal that this drug makes an impression 
upon the disease after a few days' administration. 

Andeer publishes surprising results from the administration of small 
quantities of resorcin. 

Cannabis indica has been used where opium or chloral cannot be 
given, and where a narcotic is indicated. 

Ergot is still vaunted as a specific, but it possesses no action over 
the disease. 

Senega, lobelia, checken, grindelia, clover, tartar emetic, terebene, 
turpentine, and other expectorants, are still supposed to act benefi- 
cially and sometimes specifically upon the paroxysms. 

Hydrocyanic acid is occasionally very useful in relieving cough and 
spasm. 

Gelsemium, though a dangerous drug for very young children, is 
sometimes recommended where the spasmodic element is unusually 
well marked. 

Valerian, asafcetida, camphor, ergot, musk, and sumbul, are also 
recommended in these cases, and there are still those who believe in 
the internal administration of the dilute nitric acid. 

A blister to the nape of the neck sometimes seems to lessen the 
amount of spasm, and leeches applied to the same region, or to the 
larynx, have been recommended, as have also been Leiter's tubes and 
iced compresses. 

In the later stages of the disease there is nothing so valuable as a 
change of air, and the old plan of bringing children to the gas works, 
and allowing them to breathe the fumes of gas-lime has been often 
found to lead to rapid improvement. Various plans have been 
devised to carry out some treatment upon the same principle at home, 
without exposing the children to the vicissitudes of weather. The 
various inhalations already mentioned have been employed with this 
intention, and the odor of coal gas, of sulphuretted hydrogen or sul- 
phurated potassium solutions have been recommended. Of all such 
measures, however, the plan of sulphurous acid fumigation, as carried 
out by Mohn, is by far the best. The writer has seen excellent results 
from it in the later stages of the disease, and he believes it should 
always be employed occasionally during the middle and several times 
toward the end of the treatment of every case of whooping-cough. 

The plan consists in removing the patient from his sleeping-room in 
the morning, after which sulphur is freely burned in the room (6 h 
drachms per cubic metre of air space), with the door and windows 
closely shut, for at least five hours. After opening all outlets and 
inlets, and ventilating the room until the air can be safely breathed, 
the patient, with clean linen garments, is to be brought back in the 
evening and put to bed, and Mohn maintains that he awakes cured 
next morning. Certainly, sometimes the paroxysms appear to rapidly 
diminish after this procedure. 

In the convalescent stage remedies which improve nutrition may be 



PHARYNGITIS, ACUTE. 625 

given. Cod-liver oil and syrup of iodide of iron are the best of these. 
Arsenic in small doses is of use when convalescence is protracted, and 
counter-irritation by means of stimulating liniments to the chest is 
useful in all stages of the affection. A favorite external application is 
the oil of amber, which is also given internally ; but the most valuable 
liniment is, in the writer's opinion, the oil of eucalyptus, which may 
be applied alone or with an equal quantity of olive oil or spirits of 
camphor. By this means, if freely used, the patient often breathes for 
a short time in the day and at bed-time a purified atmosphere. 
The following application may be used : 



a a 



lij- 



H • — Olei eucalypti 
Lin. camph. 

Olei cajuputi 3^ y - 

Olei mentha? pip gij.— M. 

S. — To be used as directed. 
PETIT MAL-See under Epilepsy. 
PHAG-EDJENA— See under Gangrene (Hospital). 

PHARYNGITIS, Acute. 

The treatment in severe cases will consist in a smart saline purge, 
and the administration of any simple diaphoretic mixture, as : 



R. — Liq. ammon. acet. . 
Spt. aether, nitrosi . 
Tinct. veratri vir. 
Aquae camphorae 
S. — One tablespoonful to be taken ever 



.... gij. 

. £iv. 

. . . . tllxx. 

ad ^viij. — M. 
y second hour. 



To the throat may be applied a weak solution of carbolic acid, with 
or without cocaine, either in the form of gargle or spray, as : 



li . — Acidi carbolici . 

Cocainae hydrochlor. 
Pulv. sodii bor. 
Aquae rosae 



• 3J- 

• gr. viij. 

• 33- 

ad ^xij. — M. 



This makes an efficacious gargle, and it can be painted frequently 
or sprayed over the inflamed membrane when there is any difficulty in 
using a gargle. It is also a good remedy in those cases where the 
larynx has become affected, as shown by hoarseness and pain in speak- 
ing, as well as in swallowing. In such cases, as a rule, steaming the 
throat by holding the face over a large basin of boiling water and 
covering the patient's head and shoulders with a sheet is very soothing, 
and helps to cut short the attack. 



626 PHARYNGITIS, ACUTE. 

At a later stage or in mild cases from the first an astringent gargle, 
such as is useful in chronic cases, may be very beneficial. Salol has 
recently given good results in acute pharyngitis. It is, however, more 
clearly indicated, and will give more satisfactory relief in acute tonsil- 
litis. 

Chronic catarrhal pharyngitis "or relaxed sore-throat," may be a 
very troublesome complaint, though not associated in any way with 
any danger to life. The first step in the treatment will be to remove 
the cause when this is evident. Two common factors, if not removed, 
will often render all treatment useless. These are excessive indulgence 
in tobacco and alcohol. Chronic dyspepsia and gout are also causes 
requiring attention, and the affection is most frequent in those follow- 
ing indoor sedentary occupations associated with late hours and bad 
ventilation. 

Tonics and measures which improve the general health, as iron, 
quinine, cod-liver oil, good food, pure fresh air, a prolonged holiday, 
or what is of the greatest importance to the hard-worked city slave, is 
to insist upon his sleeping outside the smoke and dust of the town in a 
seaside or rural suburb. 

The efforts of continual hawking or clearing the throat, especially in 
the morning, tend to greatly aggravate the mischief, and these should 
be suppressed as much as possible by the patient. A course of bromide 
of potassium has a very marked influence in diminishing the sensibility 
of the pharyngeal membrane, but a simpler method by far, and one 
not associated with any depressing effects, is to apply a weak carbolic 
solution to the parts. 

This may be accomplished by using the carbolic gargle or spray, 
mentioned upon the previous page, for a few minutes every morning, 
The same effect can be produced during the day by sucking a carbolic 
acid lozenge. Not only is the sensibility of the pharynx lessened by 
this plan, but the palatal muscles are partially paralyzed, and the 
incessant efforts at swallowing are arrested and the irritated membrane 
is put in a state of comparative rest. Sometimes in severe cases the 
glycerin of carbolic acid (1 : 4), diluted with twice its bulk of glycerin 
or water, may be brushed over the pharyngeal mucous membrane with 
a large camel's-hair pencil. 

After the irritation has been somewhat diminished, astringent appli- 
cations should be constantly made to the chronically inflamed mem- 
brane. The glycerin of tannin (1 : 4) is a favorite remedy painted on 
with a brush night and morning, but it very often fails to produce any 
benefit. The glycerin of alum (1 : 5) is better. Tannin dissolved in 
ether is said to be much more valuable than the glycerin preparation. 

Chloride of zinc, 15 grains to 1 ounce of water, and nitrate of silver, 
15 to 30 grains to 1 ounce, are both useful for local application. They 
can be used in the form of spray if made of half this strength. 

Chloride of ammonium, chlorate of potassium, alum, sulphate of zinc, 
bicarbonate of sodium, chloride of sodium, are used as gargles 10 



PHARYNGITIS, GRANULAR 



627 



grains to 1 ounce, or as sprays, or swabbed on with a small mop of lint 
or a large brush. 

The writer's favorite gargle is the following : 

H. — Acidi carbolici 3j. 

Acidi tannic! gij. 

Glycerini pur if. ^j. 

Tinct. capsici gj. 

Infusi rosne acidi ad §xij. — M. 

S. — To be used frequently. 

This solution can be mixed with water at first in equal proportions 
ond the amount of dilution can be gradually lessened until the gargle 
is used in its full strength. It may likewise be used as a swab or 
spray. 

The excellent tabloids consisting of borax, chlorate of potassium, and 
cocaine, are most elegant and efficacious if slowly sucked in the mouth 
and the saliva swallowed. The tincture of iodine and glycerin, in equal 
quantities, is a valuable local alterative when swabbed over the pharyn- 
geal membrane. Recently the writer has obtained excellent results 
from a mixture of 1 part of the tincture iodine and 7 of the glycerin 
of alum (1 : 5), painted on morning and night. Trichloracetic acid, as 
recommended by Stein and as described under next article, may be 
used. 



PHARYNGITIS, Granular. 

The same advice regarding the treatment of causation must be fol- 
lowed out as in the case of simple chronic pharyngitis. Little progress 
need be expected until the patient changes his mode of life very con- 
siderably. The writer attaches great importance to the patient 
leaving city sedentary life and living in a suburban, country, or sea- 
side place. In the case of public speakers, who are subjects oi 
granular pharyngitis, a certain amount of laryngeal trouble always 
follows any special effort, and the most thorough rest of the affected 
parts that can be possibly obtained should be insisted upon until the 
treatment is well started. 

A long sea voyage often succeeds after the failure of every known 
drug ; singing, loud speaking, smoking, and over-indulgence in alco- 
holic stimulants, and rich, high-seasoned dishes being forbidden. In 
ordinary cases sea-bathing is of service, and a tricycle ride of several 
miles along the coast afterward, if the weather permits, is of great 
benefit. 

While every known means of improving the general health is to be 
persisted in, the internal administration of drugs is of little moment, 
except in so far as it assists general building up of constitutional vigor. 
Iron may be given alone, or in combination with quinine, arsenic, 
phosphorus, iodine, or cod-liver oil. 



628 PHARYNGITIS, GRANULAR. 

Free purgation, by means of any of the natural mineral waters, or a 
sojourn at Carlsbad or Harrogate, may be beneficial. 

Local treatment is always of the greatest importance. This is to be 
carried out upon the same lines as in treating chronic pharyngitis, 
soothing carbolic lotions or sprays being employed where there is 
much local pain or irritation. Any of the astringent gargles, sprays, 
or swabs may be tried, but, as a rule, little may be expected from these 
measures in very chronic cases associated with much hypertrophy or 
numerous granulations. These must be destroyed if a radical and 
permanent improvement is to be aimed at. In the great majority of 
cases a cure from internal medication and local astringents need not be 
expected. 

Nitrate of silver fused upon the end of a strong silver probe may 
be employed to destroy the granulations, only a few being operated 
upon at each sitting. A strong solution of the nitrate (1 drachm to 
1 ounce of distilled water) is a favorite means of carrying out this 
object ; but it is a mistake to paint over any considerable area of the 
pharynx with this at one sitting, owing to the irritation which may 
ensue, unless much ulceration is present. Every second or third day is 
often enough, and the carbolic lozenge or spray may be frequently 
used before and after each application. Cocaine may be employed to 
lessen the pain and irritation. Where the solid stick or strong solu- 
tion fails, the granulations may be separately destroyed by the 
galvano-cautery after swabbing of the throat with cocaine solution 
(10 percent.). Lawrence sometimes uses "London paste" for the 
destruction of the granules, but Butlin scrapes them with a Meyer's 
ring knife. 

Rualt's method of "grattage" is reported as being very successful. 
The pharynx is painted with cocaine; a hard brush with the hairs 
cut short is dipped into a 10 per cent, solution of iodine and iodide of 
potassium in water, and the mucous membrane is vigorously rubbed 
with this until bleeding occurs. After this has subsided a softer brush 
is used. At the end of about five days, when the inflammation has 
subsided, the operation is repeated once, and these two sittings are 
reported to effect a cure. 

Recently Ehrman has obtained results in chronic pharyngitis which 
far outstrip those produced by any other drug or methods of treat- 
ment. He employs pure crystallized trichloracetic acid by means of 
a probe and cotton wool. This effective caustic (author's Pharmacy, 
Materia Medica, and Therapeutics, fifth edition, page 528) destroys all 
diseased membrane without producing any pain or inflammation if 
cocaine be used previously. It can be applied to the nose and behind 
the palate. A solution (1 : 3) in glycerin may be freely painted or 
swabbed over the granular surface. 

At a later stage the chloride of zinc solution (15 to 20 grains to 
1 ounce) may be freely applied after local irritation has been soothed 
by any of the gargles, or sprays, or swabs already mentioned. As a 



phimosis. 629 

rule, however, it may be said that the gargle is the least satisfactory of 
all the forms of local applications in the management of chronic 
pharyngeal affections. 

Tincture of iodine and glycerin of alum is a very excellent solution 
for daily application with lint or a large brush. 

Bromide of ammonium solution (20 grains to 1 ounce) has been 
found very useful in subduing the irritability of the pharyngeal mus- 
cles, but the writer has had better results from its internal administra- 
tion in full doses, the effects being much less transitory than when its 
local exhibition is relied upon. 

The following gargle may be used before and after the use of the 
more radical measures : 

R. — Ammonii brom. gij. 

Cocainoe hydrochlor. . . . . . . gr. x. 

Acidi carbolici TTlxlv. 

Aquae rosse ad ^ x. — M. 

S. — To be used as a spray and as a gargle for the throat several times a day. 

The chloride of ammonium inhaler is sometimes of the greatest 
service in the later stages of treatment, and sometimes all through the 
ailment it affords some relief, especially when laryngeal irritation is a 
prominent feature. 

Syphilitic 'pharyngitis is to be treated by remedies directed to the 
primary lesion — mercury in the early stages, and large doses of iodide 
of potassium (20 or 30 grains three times a day) in the tertiary 
ulcerations. Chlorate of potassium 4 drachms, carbolic acid 1 drachm 
in 20 ounces of rose water is an excellent application or gargle for 
habitually cleansing the surface of syphilitic ulcers in this region. 
Where they fail to show any tendency to heal under this mild treat- 
ment, the writer is not afraid to touch them over with a brush 
moistened (but not dripping) in strong solution of pernitrate of mer- 
cury. The solid stick of nitrate of silver may be applied, but the 
mercurial solution used with caution is far better. The brush should 
never be applied to the neighborhood of the larynx or to the healthy 
parts of the mucous membrane. 

Iodized phenol may be used in the same- way, or the ulcers, when 
well within reach, may be insufflated with iodoform. 

The following liquid may be swabbed over the throat upon cotton 
wool : 

R. — Hydrarg. bichlor gr. j. 

Ammonii chlor. gr. vij. 

Glycerini aluminis (1:7) ^j. — M. 

S. — To be used as directed. 

PHIMOSIS. 

The treatment of this affection is almost universally regarded as 
demanding the operation of circumcision. The writer hesitates to 



630* PHIMOSIS. 

speak strongly upon a subject belonging so exclusively to the domain 
of surgery, but the experience of several years' surgical practice in a 
children's hospital, and his repeated opportunities since then of seeing 
the evils resulting from the elongated and narrow prepuce as they 
continually present themselves in medical practice, has forced him to 
form a very definite opinion upon the subject. 

After practising the operation of circumcision upon numerous 
occasions, he met with some cases in children and in adults where the 
operation would not be permitted, and being forced to try the effects 
of dilatation, he was surprised to find that in every case in which he 
had the opportunity of testing its value this measure resulted in com- 
plete success. In the case of a child whose narrow preputial orifice 
scarce admits a stout probe, a few sittings suffice to dilate the con- 
tracted opening by inserting the blades of a very fine forceps in the 
closed state, and gradually and very gently separating the handles 
until the tissues are thoroughly stretched. The ordinary old-fashioned 
phimosis forceps, opening by means of a finely threaded screw, answers 
nearly all purposes. It is almost surprising to find to what extent 
dilatation may be pushed without causing pain, cracking, or tearing 
of the prepuce. Once or twice a week is often enough, and fre- 
quently in young children the prepuce may be painlessly slipped over 
the glans after one or two trials with the forceps. When this has 
been accomplished with such ease as to render paraphimosis unlikely, 
the child's parents may be safely entrusted to periodically draw the 
prepuce back, and in the case of older children they see to this them- 
selves. In a comparatively short period the elongated prepuce 
shortens, and the writer has seen several cases where a long, narrow 
prepuce after dilatation has been found years subsequently to have 
almost disappeared, leaving the glans bare as if circumcision had been 
skilfully performed. In two cases where an extremely narrow open- 
ing had existed from the time of birth, and caused no inconvenience 
until marriage, dilatation was found to effect a permanent cure in a 
few weeks. 

Symptoms of incontinence of urine at night, bladder irritation, 
and stone, depending upon the condition of the prepuce, rapidly dis- 
appear after gradual dilatation by the phimosis forceps. These symp- 
toms, however, are rarely caused by the constricted orifice, as generally 
stated. They arise from the irritation produced by the partial or 
complete adhesion or growing together of the mucous surfaces of the 
lining of the prepuce and the covering of the glans, and this cannot 
be remedied until the orifice of the prepuce is dilated so as to permit 
of the foreskin being drawn back and peeled off the glans by forcible 
scraping with the finger-nails until the head of the penis is completely 
bared. Occasional drawing back of the foreskin in the act of mictu- 
rition effectually prevents any further adhesion of the contiguous 
mucous surfaces. 

There is no doubt that an early circumcision, as performed by the 



PHIMOSIS. 631 

Jews upon the eighth day before the parts are at all developed, would 
be a wise law for universal acceptance, but it is often a question if the 
surgeon is justified in chloroforming and performing a by no means 
trifling operation upon older children or adults when results almost 
equally good in many cases may be obtained by a painless gradual 
dilatation. 

Acquired phimosis may in many cases be successfully treated in the 
same way, after the irritation or balanitis has entirely disappeared ; 
but where a chancre or warty vegetations are found to be present, 
there should be no attempt made to dilate, but the foreskin should be 
slit up and the glans fully exposed by first passing a director through 
the preputial orifice and cutting with a sharp-pointed curved bistoury 
or fine scissors through the prepuce at its dorsal aspect. Any useless 
tissue may be snipped off, and the edges of the mucous and cutaneous 
surfaces should be brought together by catgut or fine silk sutures. 

Where in congenital phimosis the prepuce is very much elongated, 
the ordinary operation of circumcision may be performed, though the 
writer finds that the superfluous tissue often disappears. Being gradu- 
ally pulled back, it becomes part of the covering over the body of the 
penis when complete dilatation has been successfully accomplished. 

Circumcision may be performed in congenital cases by slitting up 
the prepuce as just described, but where there is much useless skin the 
older method is better. The surgeon, measuring the amount which he 
thinks necessary for removal, while the parts are in their natural un- 
stretched position, by grasping the foreskin between the tips of bis 
forefinger and thumb, applies the blades of a pair of ordinary dressing 
forceps behind his finger-nails as he puts the skin upon the stretch by 
drawing it forward. 

Clover's circumcision tourniquet may be used instead of the forceps 
blades, which are liable to slip. When the tourniquet or forceps are 
tightened the part of the prepuce in front of it is shaved clean off with 
a sharp knife or pair of curved scissors. After removing the blades 
the skin retracts well backward, but the mucous membrane, which 
still is found to cover the glans, is to be slit up well back to the corona 
on the dorsal aspect by scissors or bistoury. In very young children 
sutures are unnecessary, the edges of the skin and mucous membrane 
being held in position by a narrow strip of lint wound round the penis. 
In older patients the edges of the skin and mucous membrane must be 
neatly brought together by fine catgut sutures. 

The plan of coating over the dressings and keeping them in position 
by collodion is not to be recommended, as the writer has seen great 
trouble and intense pain caused by the removal of the application. 

Any simple antiseptic lotion may be used to keep the dressings 
moist for three or four days, after which the parts will generally be 
found to be in an advanced stage of repair. 



632 PHLEBITIS. 

PHLEBITIS. 

Absolute rest of the affected limb as the patient lies in bed is essen- 
tial. Where the veins of the leg are affected the entire limb, from the 
toes to the trunk, should be kept in a state of repose, if necessary, by- 
splints. The limb should be elevated by raising the mattress or palli- 
asse. In mild cases the tincture of iodine brushed over the course of 
the inflamed vein often affords speedy relief. In severe cases iodine in 
weaker solution may be once brushed over the course of the affected 
vein, after which hot fomentations a few hours later on may be tried 
if the pain be very acute. The writer's routine method of treating 
severe cases of extensive phlebitis, arising out of varicose veins, is to 
envelop the entire leg in warm absorbent wool, over which a layer of 
thin mackintosh is spread so as to cover completely at every point the 
wool from the toes to the groin. This dressing is kept in accurate 
position by the even pressure of a skilfully applied woven bandage. 

This application should not be interfered with for twenty-four hours, 
when the wool is to be replaced by a fresh coating. Poultices are cer- 
tainly much inferior to this method and should only be applied when 
suppuration occurs. A local phlebitis affecting only a limited area 
should also be treated by absolute rest of the entire limb in order to 
avoid the detachment of the thrombus, and the application of the ordi- 
nary spirit lotion (1 of spt. vini rect. to 3 of water) upon lint, which 
is to be covered with oiled silk and a bandage, affords the best and 
simplest treatment. A smart saline purge is often very useful, and 
hazeline internally and as a lotion may be tried. 

The following may assist in the solution of the thrombus : 

R. — Ammonii carb. ^ij. 



Spt. amnion, aromat. 
Potassii iodidi . 
Hazelini . 
Glycerin! et aquae . 



. 3j. 

■ 3ij. 
ad §vj.— M. 



S. — Two teaspoonfuls in a large wineglassful of water four times a day, after 
food. 

Abscesses must be freely incised as they appear, and attention should 
be directed to the antiseptic management of any ulcer, wound, or in- 
jury to which the phlebitis is secondary. 

In diffuse suppurative phlebitis the grave constitutional condition 
must be met by abundance of stimulants and concentrated liquid 
nourishment and large doses of ammonia. Operative measures for the 
removal of any injured part which has been the starting-point of the 
general pysemic infection may be undertaken , though there is but 
slight hope of a successful issue in such cases. 

At a later stage oedema and local thickening may be removed by the 
pressure of an India rubber bandage. This is much to be preferred to 
the ordinary elastic stocking. Massage is not to be recommended 



PHLEGMASIA ALBA DOLENS. 633 

owing to the risk of detaching clots or thrombi. Strapping the limb 
with mercurial plaster hastens the absorption of effused inflammatory 
products, and benefit may be obtained from the internal administration 
of large doses of iron, quinine, or iodides. The rubber bandage should 
be worn until long after the disappearance of all thickening, and in 
the case of varicose veins it should be used daily for the remainder of the 
patient's life. 

Blood-letting, leeching, mercury, and other antiphlogistic measures 
are generally contra-indicated, but leeching is sometimes useful at the 
very commencement of a localized periphlebitis. 

PHLEGMASIA ALBA DOLBNS. 

As this affection is generally found as a complication of the puer- 
peral state the general condition of the lying-in patient should receive 
careful attention, and no harm can come of the physician insisting 
upon thorough irrigation of the vagina, and in special cases of the 
uterus with some mild and unirritating antiseptic solution as weak 
Condy's fluid or boric acid lotion, if such have not already been em- 
ployed, provided always that its application does not interfere with the 
chief measure,^, e., rest. This is to be as complete and thorough as 
possible. If the patient has already got up and moved about she must 
be put back to bed. The position of lying upon the back on a hard 
hair-mattress is the best, by elevation of the mattress or palliasse the 
limb should be slightly elevated above the level of the trunk. 

Where there is marked fever at the onset, a full dose of quinine, or 
a diaphoretic mixture coutainiug \ minim of tincture of aconite and 
3 or 4 minims of solution of morphine (1 : 100), with spirit of nitre 
and mindererus spirit, should be prescribed. 

Pain will require opium, but rarely will this be needed in large 
amount. A good routine treatment will be to put the patient upon a 
pill consisting of \ grain extract of opium, and 2? grains of quinine 
every six or eight hours. A smart saline purgative should be admin- 
istered from time to time. 

In severe cases the child should be weaned. 

Local treatment is of the greatest importance. As a rule, this is 
much overdone. Leeching is seldom required, and irritating applica- 
tions or blisters are to be avoided. The usual treatment of applying 
warm or hot fomentations is not to be recommended, nor are poultices 
advisable or convenient. It may be laid down as a rule that any 
method of treatment necessitating frequent manipulations or changes 
of posture of the affected limb is to be condemned. The danger of 
dislodging clots or thrombi is to be always kept before the mind of the 
physician, especially as phlebitis is also commonly present, and for this 
reason friction of all kinds must be avoided. The best method to 
pursue is that just mentioned under the head of Phlebitis. The limb 
is to be carefully covered from the toes to the groin with a uniformly 
thick layer of absorbent cotton wool, after which one large piece of 

41 



634 PHLEGMASIA ALBA DOLBNS. 

thin mackintosh is to be used to cover the entire limb, so as to permit 
of no part of the wool being visible. Over all a broad, soft, woven 
bandage is to be evenly applied. This dressing need not be disturbed 
for several days if the effect of a poultice be desired, and when it is 
removed the skin of the limb will be found moist and wrinkled, as if 
after long immersion in water. As a rule, where pain or tension is not 
very great, this maceration of the limb is not necessary, and the wool 
may be changed daily. As already mentioned, the limb should be 
elevated by raising the mattress. In the great majority of cases the 
above treatment is all that is required, and if commenced at the earliest 
stages, much pain and tension will be prevented. When the case is 
not seen till the swelling and discomfort are at their height, relief may 
be more quickly obtained by enveloping the limb in a double layer of 
flannel bandages wrung out of hot water, over which the mackintosh 
may be adjusted and kept in position by a light calico or stocking web 
bandage. Laudanum, belladonna, chamomile, decoction of poppy 
heads, or other anodynes may be added to the hot water, but they are 
seldom required. 

As the acute stage passes off the wool is to be retained, but the 
mackintosh covering may be dispensed with when the firm, painless, 
doughy swelling has become established, the wool being firmly but 
comfortably bandaged by a woven fabric. 

At a later stage a soft, dry flannel bandage may be applied and 
renewed morning and night, the limb being occasionally sponged over 
with a little tepid water, but friction with oils or liniments is to be 
forbidden for the reasons already mentioned. The patient may now 
be permitted to leave her bed for a comfortable couch, but exercise of 
the affected leg is to be very cautiously permitted until all danger of 
detaching clots or thrombi has passed away. There is considerable 
difficulty in restraining nurses from rubbing the limb at this stage. 

After the patient begins to move about, if the swelling remains, there 
is no remedy so valuable as the India-rubber bandage applied every 
morning before getting out of bed, and taken off after she goes to bed 
at night, when a thin flannel roller may be substituted. 

This continuous elastic pressure has been found by the writer to 
speedily and permanently remove doughy swelling which had existed 
for many months, and in one case for several years. The continuous 
current is now of considerable use, and massage may be most valuable, 
with the occasional use of iodine applications for a few days, while the 
patient keeps her bed. Friction, with the lin. potass, iod. cum sapone, 
B. P., or cod-liver oil, is also of great use. 

The rubber bandage is infinitely more valuable than the old-fashioned 
elastic stocking, which should be discarded. 

Seldom are mercurial dressings or inunctions indicated. 

Warm salt baths may be tried in very chronic cases and the brine 
baths of Droitwich are excellent. 



PHOSPHATURIA. 635 

Hamamelis and hazeline, though much vaunted, are of little use in 
this affection. 

The chief indication in the late stages of the affection is iron in 
combination with iodides and small doses of tincture of digitalis. 

PHLEGMON— See Erysipelas. 

PHOSPHATURIA OR PHOSPHORIC ACID DIATHESIS 

There is, strictly speaking, no such condition as Prout's phosphoric 
acid diathesis. The condition simply means alkalinity or diminished 
acidity of the urine, which is a feature in many different diseased con- 
ditions. The treatment of the primary affection is thus of chief import- 
ance. Dyspepsia, insomnia, and the exhausted conditions arising out 
of prolonged severe mental overwork or worry, are to receive appro- 
priate treatment. 

Change of scene to a mountainous or seaside region, rest of mind, and 
active exercise of the body in the open air, with boating and bathing 
and a generous animal diet, are the best remedies. Of internal reme- 
dies, the diluted nitro-hydrochloric acid in full doses is always of con- 
siderable value, though its action can only be likely to prove useful by 
its general tonic effect upon the system. Drugs, such as the mineral 
acids, generally fail in relieving those cases where the phosphatic de- 
posit in the urine depends upon the constant alkalinity produced by 
fixed alkali, nor is there any great reasons for active drugging, as cal- 
culi seldom form out of the amorphous phosphate of calcium. The 
indications, as above stated, are not for chemicals, but for measures 
calculated to improve the general health. 

The same remarks apply to some extent, also, to those cases where 
the phosphatic deposit is caused by volatile alkali, but local treatment 
is of the greatest importance, and Roberts has shown that the injection 
of 1 drachm of dilute nitric acid into the bladder when diluted with 
10 ounces of warm distilled water once daily soon dissolved the phos- 
phatic deposit which rapidly formed upon the surfaces of an old calculus 
which had been crushed with the lithotrite. 

The bladder must be brought into a healthy condition, and ammo- 
niacal urine should be remedied or prevented by the most scrupulous 
cleanliness as regards catheters, sounds, etc., and by the frequent irri- 
gation of the bladder by a weak nitric acid injection. Since first using 
boric acid internally in bladder affections associated with an arnmo- 
niacal or putrid state of the urine, the writer has almost ceased to wash 
out the organ, as already mentioned. The effect upon the urine of 
even small doses (8 to 10 grains) of the acid by the mouth is generally 
surprising. 

PHOSPHOROUS POISONING— See Poisoning. 

PHOTOPHOBIA— See Under Conjunctivitis, Cornea, etc. 



636 PHTHIR1ASIS — PHTHISIS. 

PHTHIRIASIS. 

The treatment of the cause of this affection is described at length 
under Pediculi. After means have been undertaken for the destruc- 
tion of the parasites, the excoriations, eczema, impetigo, and other 
lesions produced by scratching or by the irritation of the insects, should 
receive appropriate treatment. Their managsment is detailed under 
the heading of each affection, and appropriate remedies must be used 
when they do not rapidly subside. 

PHTHISIS. 

The treatment of pulmonary phthisis requires more space than can 
be devoted to it in the narrow limits of the present volume. Hence 
only an outline of the most approved methods of dealing with the dis- 
ease will be attempted. At the outset the question must be answered — 
Is phthisis curable ? The weight of all respectable authority is every 
year becoming more and more emphatic upon this point, and a decided 
answer in the affirmative must be given by every observer who ap- 
proaches the problem with an open mind. As already pointed out in 
discussing the treatment of various other affections, the secret of suc- 
cess often depends upon the spirit in which the physician and patient 
enter upon the struggle with the disease. 

Until within the past few years the discovery of a tubercular deposit 
in any region of the body was almost universally regarded as leading 
to a fatal issue. The recent strides made in abdominal surgery must 
convince the most sceptical that extensive tubercular disease of the 
peritoneum which has been seen and handled by the surgeon has been 
proved beyond doubt to be curable in many instances. The physician 
who regards as a case of mistaken diagnosis every case of pulmonary 
phthisis which has yielded completely to treatment, is certainly not 
keeping abreast of the tide of progress and knowledge. 

The successful treatment of pulmonary disease may be, upon the 
other hand, also seriously retarded by the blind belief in the efficacy 
of many drugs which, at the best, can only be said to possess feeble 
action over the affection. Nevertheless, the impartial observer must 
be convinced that very substantial progress is being made since the 
days of leeching, blistering, and antiphlogistics. 

Drugs should play a very minor part in the treatment of phthisis. 
The main reliance must be placed in hygienic measures, as soon as the 
family history, symptoms general and local, and the physical signs 
warrant the physician in arriving at a diagnosis of the disease. 

The writer is accustomed to keep ever before his mind in dealing 
with phthisical patients the facts demonstrated by Metschnikoff and 
applying these to the treatment of phthisis. He regards the question 
of its cure as being one of " phagocytosis." It will probably be demon- 
strated soon that the agent which so modifies the action of the phago- 
cytes as to secure the proper performance of this process will be the 



PHTHISIS. 637 

one upon which our hopes are to depend for destroying the disease. 
(See this question discussed along with Koch's lymph under the heading 
of Tuberculosis.) 

The clothing of the phthisical patient in this country, if left to his 
own choice, is almost certain to be injurious. He selects heavy gar- 
ments, and wears too many of them, so that the least exercise induces 
perspiration and increases the risk of chills. Woolen garments should 
be worn next the skin, and in winter these may be changed for heavier 
or thicker ones of the same material. They should be changed often. 
In very severe winters a chamois vest may be worn, but if so, it is better 
to have it perforated ; it may be worn over a light merino fabric. 

The fabrics should be such as will speedily absorb perpiration, and 
it is much better to arrange for moderate extremes of temperature by 
overclothing which can be easily removed. A light overcoat, which 
can be easily put on and off in summer, will enable the patient to do 
with less underclothing, and in this way continual overheating and 
chills may be avoided after exercise. The feet and legs should be pro- 
tected against damp and cold. It is more difficult to arrange the cloth- 
ing of lady patients ; but such directions should be given as will lead 
them to sacrifice their ideas of fashion to their health, for, although a 
matter of detail, it is a very important matter. Too much clothing is 
often a more serious mistake than too little. In driving or travelling 
the warmest coverings are essential. 

Food is of far more importance than medicine, and practically there 
need be no limit set to its amount. As much as the patient can be 
tempted to swallow may be administered. A well mixed or varied 
diet is the best for a consumptive patient in the early stages. It should 
be carefully cooked, and served in the most tempting fashion, and the 
writer has sometimes felt that a good cook was of more importance than 
a therapeutist. Fats should, when possible, form an important item in 
the daily food, and an abundance of milk, eggs, and butter is generally 
within the reach of all, and they do not demand in their preparation 
much scientific knowledge of cookery. When the temperature is ele- 
vated, and the digestive organs weakened, the patient may have to rely 
entirely upon a milk diet, and experience has proved that this of itself 
is a most valuable dietary in all stages of phthisis. Some patients can 
take cream. To live upon milk, four pints, at least, in the twenty-four 
hours, will be required to meet the demands made upon the system ; 
but as the great aim in dealing with phthisical patients is to administer 
more than is required to meet the waste, and to so improve the nutrition 
as to considerably add to the body weight, a much larger quantity will 
be necessary. 

In some of the " milk cure" establisments more than double this 
amount is given. When the patient objects to raw milk, it may be 
cooked in various ways, or mixed with kali or lime-water, or made 
into whey or koumiss. As already stated, good buttermilk turned 
slightly acid, is one of the most valuable and palatable of foods, and is 



638 PHTHISIS. 

often relished and taken in great quantity when every other form of 
milk is distasteful. A favorite beverage with milk drinkers is to mix 
equal quantities of fresh cow's milk and buttermilk together. Milk, 
warm from the cow, is believed to be more digestible than the cold 
liquid. A little good rum added is a great improvement. Jaccoud 
advises phthisical patients to repair twice a day to the cow-house to 
drink the milk warm from the milking pails, and to inhale the moist 
sedative atmosphere of the place for some time, so as to have laryngeal 
and bronchial irritation soothed. 

Where the digestion is weak, the milk may be peptonized by Fair- 
child's, Savory & Moore's, or Benger's preparations. Rennet is often 
relished when these are distasteful. 

The milk of the mare, ass, goat, and sheep may be used, and the first 
two kinds of milk are easily digested. The koumiss made from the fer- 
mented milk of the mare is a highly-prized Russian remedy for phthisis. 
The English koumiss, made from cow's milk, and supplied by the Ayles- 
bury Dairy Company, may be used instead ef the natural Russian arti- 
cle. This food is of no use unless it can be procured and used in large 
amounts, and patients soon weary of .sending for it. The writer has 
had great satisfaction from home-made preparations, and when patients 
are taught to make their own beverage from materials which they know 
to be free from any objection, they often take it when they object to a 
foreign article, like the Russian koumiss or kefir. 

Either of the forms given upon page 578 of the 5th edition of the 
writer's book on Materia Medina and Therapeutics may be used. That 
of Ponomaroff is sooner ready for use. 

In the absence of yeast, a palatable and highly nutritious beverage 
may be prepared by mixing one part of fresh rich buttermilk and one 
part of water with eight parts of cow's milk, adding a very little loaf 
sugar, putting the mixture into a loosely- corked gallon jar, leaving it 
in a warm, but not hot, place beside the fire, where it may be fre- 
quently and briskly shaken, and in thirty-six to forty-eight hours it is 
ready for use as a pleasant, sharp -tasted, thick liquid, which slightly 
effervesces. Some little skill and experience is required in producing 
a uniform result, and the patient should not give it up if the first and 
second results are unsatisfactory. After the first batch of this artificial 
koumiss has been successfully prepared the use of buttermilk may be 
entirely dispensed with, as an equal bulk of the koumiss liquid can be 
used instead, in the preparation of each subsequent quantity. Some 
patients succeed best by leaving out the sugar entirely, and by shaking 
the mixture very seldom during the first twenty-four hours. Where a 
phthisical subject takes to this home-brewed koumiss, as a rule all diffi- 
culty in feeding is overcome ; but the article known as buttermilk in 
England will not make koumiss. The artificial kefir mentioned in the 
volume above referred to is made upon a somewhat similar principle. 

In the intervals between feverish attacks, animal food in abundance 



PHTHISIS. 639 

may be given. Beef tea is admissible when little else can be got down, 
but too often phthisical patients are starved upon it. 

Raw meat is a favorite dietetic agent in treating phthisis in France. 
The meat is passed through a mincing-machine, scraped with a knife, 
pounded in a mortar, or rubbed through a seive, or rolled into pellets 
and covered with chocolate. 

Fish, poultry, game, oysters in abundance, and, in fact, every food 
which is considered easy of digestion and highly nutritious may be 
allowed without stint, always provided that farinaceous, fatty, and fat- 
forming stuffs are allowed a good place. Weber objects to potatoes 
and all foods which contain potash salts, which, he argues, encourage 
the growth of the tubercle bacilli. 

Malt extract is of great value, but the writer prefers to administer 
it in combination with cod-liver oil, which will be referred to when 
speaking of drugs useful in phthisis. 

The system of forced feeding, over feeding, or "suralimentation " 
introduced by Debove, consists of introducing a soft rubber stomach- 
pump tube, and filling the stomach with liquid food, as milk broths, etc. 
In this way he finds food is always retained when everything is rejected 
after swallowing. Meat dried and powdered is mixed with milk until 
a uniformly fluid compound is obtained, which is given until finally 
the equivalent of three pounds of meat is administered daily by the 
mouth without the tube. Excellent results are reported from this 
treatment, and Debove maintains that the suralimentation augments 
combustion, and so enriches the blood as to prevent the growth and 
development of the bacilli. From the writer's point of view, he would 
explain these results by supposing that the suraliment method stimu- 
lated phagocytosis. 

Yeo gives the following scheme as a suggestion for a dietary for the 
consumptive patient : 

" On waking in the morning a tumblerful of mil£ should be taken 
mixed with a little hot water, to which it is often useful to add a few 
grains of common salt and bicarbonate of sodium, especially when a 
certain amount of accumulated mucus has to be got rid of by expecto- 
ration. There is no objection to taking a little tea, coffee, or cocoa at 
this hour, with milk or cream if preferred. Sometimes the stimulus of 
a tablespoonful of brandy, rum, or whiskey is needed at this hour. 
The first meal is often best taken in bed. About an hour afterward a 
substantial breakfast should be taken consisting either of broiled bacon 
and lightly-boiled eggs, or some fresh fish, or some cold meat, or game 
or poultry, and with this meal, milk or cocoa, or coffee or tea, or some 
good, sound, light wine and water may be taken according to taste. 

" Supposing this meal to be taken about nine or ten o'clock, a glass 
of milk or a cup of beef tea may be taken about noon. 

" Half-past one or two o'clock is a good hour for the chief meal of 
the day. This should consist of some fish, when it can be procured 
fresh and good, together with some meat, chicken, or game, and fresh 



640 PHTHISIS. 

vegetables, and some light milk-pudding, with a little marmalade or 
other cooked fruit. With this meal half a pint of good Hungarian 
wine, light claret or Burgundy, or an equivalent quantity of brandy or 
whiskey and water may be taken. 

"At five in the afternoon, another glass of milk should be taken, or 
a cup of thin chocolate, or tea with plenty of milk or cream, or the yolk 
of an egg beaten up with a little brandy and water may be substituted, 
if preferred. It is rarely desirable to order any solid food at this hour, 
if it is intended that the patient should make another substantial meal 
at seven. At this hour a meal similar in all respects to that taken at 
half-past one or two o'clock should conclude the substantial feeding of 
the day. 

"About half an hour before bed-time (which should not be later than 
ten or half past), another glass of milk prepared in the same manner 
as that in the morning, together with one or two tablespoonfuls of 
brandy or whiskey, or a cup of arrowroot or beef tea, or tapioca soup, 
according to taste, may be taken. Finally, some provision of light 
nourishment mixed with a little stimulant, should be arranged, in 
order to be taken during the night when woke by coughing, or after 
perspiration, or when merely restless. 

"A glass of Vichy water taken warm half an hour before meals, as 
recommended by Germain See, may be found useful in some cases to 
promote the secretion of gastric juice. 

" In distinctly febrile cases a much more fluid dietary will have to 
be allowed, and the food will require to be taken at shorter intervals." 

The question of alcohol in large quantities in the treatment of 
phthisis has led to sharp differences of opinion. Flint mentions the 
case of a young woman, Avhere twenty ounces of whiskey were used 
daily for two years, and the patient recovered. As a rule, it may be 
said that stimulants are not advisable in the early stages, except where 
experiment proves that they increase appetite and assist digestion. 
They should always be administered along with the food, and any good, 
sound, light wine may be permitted. 

In the stages of the disease where softening of the lung has occurred, 
Whiskey may be allowed in fair quantity, and if mixed with the 
patient's milk any reasonable amount may be allowed without danger 
of doing harm. By giving it in this way, cough may be eased, diarrhoea 
checked, sleep produced, fever diminished, and waste retarded. It is 
obvious that in the class of cases referred to, a fatal issue is most likely 
to be the outcome of the disease, and therefore the moral objection to 
creating an alcohol habit is not so serious as under other circum- 
stances. 

Fresh air is of almost equal importance to food, and it is perhaps 
to the recognition of this fact more than to anything else that the im- 
provement in the management of phthisical cases has been owing. 
Dr. Henry MacCormac, by his early appreciation of the evils attend- 
ing the inspiration of re-breathed air, has done more for the preven- 



PHTHISIS. 641 

tion and treatment of pulmonary consumption than any other pioneer 
of progress. 

Day and night the most free ventilation of sleeping and sitting 
rooms, or apartments in which the patient is carrying out his daily 
avocation, is of the utmost importance. This is a difficult part of the 
treatment to carry out effectually, as phthisical patients, owing to their 
being constantly too heavily clothed, soon become abnormally sensitive 
to currents of cool air, and the horror of "draughts" or "catching 
cold " is a bugbear which must not be permitted to take entire posses- 
sion of the patient. The writer is inclined to think that the tendency 
to catch cold, which is undoubtedly present in most phthisical patients, 
is engendered by the excessive clothing generally worn. It is rare 
that the patient can be induced in this climate to sleep with the bed- 
room window open all night, and the physician should insist upon a 
free egress of the vitiated air. A talc ventilator put into one of the 
chimney flues, and a Toban's tube, or Tait's thermic ventilator, are 
most valuable additions to the host of remedies. The situation of his 
bedroom should be such as will prevent the exposure to cold east or 
north winds, and his residence should be upon a dry sandy and not 
upon a moist clay soil. 

All his available spare time should be spent in the open air, and by 
wise wrapping in suitable clothing he should so continually accustom 
himself to an outdoor life as to be able to expose himself without 
danger, even in unpromising weather. 

All sorts of outdoor games, amusements, and exercises should be 
freely encouraged, and whatever tempts the patient to remain as short 
a time as possible in the house should be cultivated. The amount and 
kind of exercise must of course be tempered to the condition of the 
patient ; and where there is a constant tendency to haemoptysis, row- 
ing, cricket, lawn tennis, or other active exercise must give way to 
sailing, driving, or leisurely walking. In city clerks and those leading 
a sedentary life, where open-air exercise must be very limited, if found 
in the early stages gymnastic exercises in a lofty, well-ventilated gym- 
nasium are often of much value ; and Williams advised these to be 
pushed even to the extent of producing emphysema in the diseased 
lung, as others have advocated bugle or trumpet practice with the 
same object in view. Horse-riding or cycling may be freely indulged 
in. 

In those cases where cure has followed change in occupation and 
climate the factor probably deserving the most credit has been the 
open-air life which has been thus forced upon the patient, and of all 
the hygienic measures advocated in the treatment of pulmonary con- 
sumption this must be regarded as the most vital. 

Therefore, when possible, the patient should be induced to give up 
his occupation for one which will allow him the longest time in the 
open air ; and habits of life which interfere with outdoor exercise in 
the wealthy must be given up if the disease is to be checked. 



642 PHTHISIS. 

It is sometimes astonishing to observe the results which follow upon 
a patient being thus lifted out of his unhealthy environment ; and one 
might say that, given a case of phthisis in the early stage, the progno- 
sis will chiefly depend upon the extent to which the habits and envir- 
onment of the patient are susceptible of improvement. Hence the 
necessity of the most rigid investigation into every surrounding of the 
victim of phthisis in the early stages. 

Climate is a factor of great importance, and as improved methods 
of travelling have brought temporary or permanent change of resi- 
dence within the reach of most patients, the question of climatic treat- 
ment is daily becoming more important, and many volumes have been 
dedicated to the elucidation of this valuable means of combating the 
disease. Unfortunately, much difference of opinion exists among 
those who have given special attention to the subject of health resorts, 
regarding the relative value of various localities ; and it is therefore 
most difficult to lay down general rules for the guidance of prac- 
titioners in selecting the best climate for individual cases of 
phthisis. 

Looking at the subject broadly, the writer is accustomed to 
formulate for himself the general rule that the climate which affords 
the greatest facilities for spending the largest amount of the patient's 
time in the open air is one most likely to lead to the best results in most 
cases. 

It is, therefore, wise in approaching the climatic method of treat- 
ment to regard it chiefly, but not altogether, as a mere variation of 
the open air or out door plan of treating phthisis. Climate will gen- 
erally be found to accomplish little if the patient carries with him his 
sedentary habits, late hours, and dislike to open-air exercises, and it is 
the duty of the physician to impress upon him forcibly that it is not 
the climate per se that is the chief or only factor, but that he must 
avail himself to the very fullest extent of the opportunities of spend- 
ing all his time in the open air which is impossible in his own variable 
climate. 

The advantages obtained by a long sea voyage are, perhaps, greater 
than those resulting from a residence in any health resort for a similar 
period of time, and upon the whole it is deservedly held in the highest 
esteem as a therapeutic agent. A long voyage in a good sailing ship 
from England to Australia is a powerful remedy in restoring the 
phthisical patient to health. It is here that the maximum amouut of 
a perfectly pure atmosphere can be enjoyed from early morning until 
late at night. Exercise can be had all day, and Professor Charteris 
advises that a pedometer should be used to mark the mileage, which 
should be two miles before breakfast, three before luncheon, three 
before dinner, and two before turning in at night. This is worth 
noting, as there is danger of the patient being seized with that listless 
idleness which sometimes paralyzes every tendency to exertion when 
at sea. 



PHTHISIS. 643 

Hemorrhage is no barrier to the ocean voyage, and except the con- 
sideration of discomforts from the absence of home luxuries, isolation 
from friends, and the risk of the complications and exacerbations 
which are liable to happen also upon land, even advanced cases of the 
disease may be safely committed to the risk of an ocean voyage, if the 
patient be informed of his exact position. The practice of sending 
patients away in the last stages of the disease in search of health when 
death is soon inevitably near, is to be condemned, but some patients, 
who, in the advanced stages of phthisis, take the notion of a long 
voyage and persist in carrying it out in spite of the remonstrance of 
their friends and physician, often return wonderfully improved. Cases 
of limited first or third stage of hemorrhagic phthisis where the 
patient's strength is unequal to much exercise, and where he has suf- 
fered from close confinement in a crowded city is, in the opinion of 
Williams, those most likely to be benefited by a long sea journey. 

The ocean journey may be undertaken in a sailing vessel about the 
middle of September, so that the return of the patient may fall in with 
the early summer after the disappearance of the dreaded east wind. 
It does away with the difficulty of selecting a health resort unless this 
problem will require to be met after his return. 

Where a journey to Australia or New Zealand is out of the question 
the health resorts nearer home may be considered. Bournemouth and 
Ventnor are the best suited for the majority of cases, and it is the 
experience of the writer that excellent results may be obtained from 
a winter in the first mentioned, often better than when the patient has 
to put up with the fatigues and inconveniences of a longer journey. 
The dry, sandy soil of Bournemouth, the shelter which it obtains 
from the prevailing winds and the beneficial influence of its neighbor- 
ing pine plantations, render it a valuable resort to those who cannot 
go further. Ventnor is to be preferred where a marine atmosphere is 
desired. Torquay where a moist sedative air is required in the pres- 
ence of extensive bronchial irritation. Rothesay is the best of the 
Scottish winter sanitaria. 

Glengarriff and Rostrevor are the chief winter resorts available in 
Ireland, and they afford excellent climatic advantages. 

The dry climates of Egypt, Tangier, Algiers, Morocco, the Riviera, 
Malaga, the Cape, Tasmania, and Australia, have been continually 
proved as of greatest benefit to the consumptive. 

Dr. Lindsay points out the dangers to which consumptives may be 
exposed in the Riviera, owing to the prevalence of the dry biting 
''mistral" wind. He, therefore, prefers Mentone as being the most 
sheltered beyond comparison of all the Riviera resorts, and especially 
suitable where there is an irritable bronchial mucous membrane, and 
an intolerance of wind. 

San Remo, though less sheltered, is drier, warmer, and more equable. 

The moist temperature of Madeira and other relaxing or sedative 



644 PHTHISIS. 

marine climates is not indicated, except where catarrhal conditions 
prevail, or where laryngeal complications exist. 

Arcachon and Biarritz are excellent autumn resorts, and the patients 
can leave them and proceed to the Riviera, Algiers, or Madeira, as 
winter sets in. 

The tendency of modern authorities is toward giving the high alti- 
tude treatment of phthisis the first trial when climatic therapeutics has 
been warranted by the history, symptoms, and physical signs. The 
extraordinary purity of the air and the low barometric pressure tend, 
with other considerations, to produce a most beneficial effect upon the 
lung tissue, which is the seat of disease, as well as to produce hyper- 
trophy, and even vesicular emphysema and expansion of the chest, as 
believed by Williams. 

It is this principle which has led to the popularity of the high alti- 
tude resorts. The stillness of the air, its great purity, rarefaction, and 
dryness, the absence of fogs and the prevalence of ozone and bright 
sunshine, render Davos a favorite sanitarium for the victims of 
phthisis. Even in the depth of winter the patient can safely sit out 
in the still pure atmosphere in bright sunshine, when the thermome- 
ter is below freezing point, and at night he can sleep with open win- 
dows. 

Appetite increases, the lungs expand, night sweats and fever subside, 
hemorrhage is less likely to occur, and many patients return without 
any symptoms of the disease, having also left their physical signs be- 
hind them. The rarefaction of the air is, of course, a most important 
factor in producing these good results. Dr. Lindsay lays stress upon 
the inadvisability of sending patients to Davos who are not capable of 
supporting and responding to the highly stimulating climatic condi- 
tions prevailing there. Where sedative measures are indicated, low- 
level climates should be selected. 

By the majority of authorities, the following classes of cases should 
not be sent to high-level resorts : 

Patients with serious cardiac or valvular lesions, much bronchitis, 
emphysema, where the symptoms are acute or the fever high, where 
there is laryngeal or intestinal ulceration, where the disease is so far 
advanced as to prevent exercise; also, the old and very young had 
better remain in low-level regions. Those of very excitable tempera- 
ments, in which insomnia is marked, and those suffering from albumi- 
nuria, should not try the high altitude, unless they have had previous 
experience of it. 

It is better that the ascent should be gradual, and early in Septem- 
ber is the best period for reaching Davos. After the expiration of six 
months, the patient may safely move toward the sea level, to return to 
Davos again in the early winter, if necessary, or he may spend his 
summer with great advantage in the Engadine, or Weisbaden, Baden- 
Baden, or Geneva. 



PHTHISIS. 645 

The Peruvian Andes and Rocky Mountain resorts are also much 
valued. Professor Charteris thinks highly of the Denver sanitaria. 

Santa Fe de Bogota, in Granada, is an ideal high altitude resort, in 
which the patient need never feel cold. 

Bloemfontein, in the Orange Free State, Kimberley, and the Trans- 
vaal are also resorts which have given excellent results, but they are 
only suited to those whose strength and vigor are but slightly impaired 
by disease, as the journey is rough and tedious. Camping out in these 
regions is a practice which, if the patient can follow it, is sure to lead 
to the best results which can be expected from climatic treatment in 
the earliest stages of phthisis. 

The treatment of phthisis by drugs, as already stated, is of con- 
siderably less importance than its management by the hygienic meas- 
ures already enumerated. This statement would, perhaps, be univer- 
sally accepted if he would include cod-liver oil as a food among the 
hygienic remedies. Cod-liver oil, if regarded as a medicine (butter 
has, however, quite as good a right to rank as a medicine), stands at 
the top of the list. Space will not permit of a discussion upon the 
various theories of how it acts in phthisis. Suffice it to say, that it is 
more easily absorbed than any other oil or fat, and that it possesses the 
power of aiding the assimilation of other foods, which would not be 
absorbed except in its presence. 

The surprising results following the inunction of cod-liver oil over 
the abdomen of children suffering from abdominal phthisis and wasting 
diseases has been already mentioned. (See page 507.) 

The methods by which the oil is dispensed or compounded in order 
to render its disagreeable taste and smell less obvious are legion. As 
a rule, the perfect emulsions are made by sacrificing the therapeutic 
value of the oil. The writer has practically abandoned all emulsions 
and compounds, and prescribes the oil in combination with the Kepler 
extract of malt, the most perfect and efficacious of all restoratives in 
wasting diseases. Occasionally its viscidity turns fastidious patients 
against it, but this is generally remedied by persevering with it for a 
time. The oil should be given always soon after food, and it is a good 
plan to be content with a small dose at bed-time only for a few nights, 
after which it may be given three or four times daily. A teaspoonful 
is enough to begin with, but half an ounce of the oil or a very large 
tablespoonful of the mixture of oil and malt extract should be admin- 
istered after each staple meal. The oil may be given with pancreas 
by the rectum. (See next page.) 

Febrile disturbance, as evidanced by a moderately high temperature 
and furred tongue, is a barrier to its use. It i3 a mistake to force it 
under such circumstances; the best plan then is to get the digestive 
organs made right first with a simple saline mixture like the following, 
which is a good formula for the sub-febrile troubles arising during any 
stage of phthisis: 



646 PHTHISIS. 

R. — Potassii bicarb. . gvj. 

Morphinse hydrochlor. . . . . . gr. f . 

Acid, hydrocyanici dil. . . . . . til x. 

Aquse dest ad ^viij. — M. 

S. — One large tablespoonful with as much fresh lemon juice, every four 
hours, to be taken while effervescing. 

Malt extracts have been used, and they are, doubtless, of value in 
assisting the digestion of starchy foods ; but if the combination of oil 
and malt extract already mentioned is tolerated by the stomach, there 
is no necessity for further use of these drugs. 

Pancreatic emulsion, containing an emulsified and pancreatized 
animal fat, is highly recommended, but to most patients it is objection- 
able, and the writer has ceased to use it. Where a pancreatic ferment 
is considered necessary or advisable to supplement or assist the human 
secretions in their digestive functions, trypsin, pancreatin, Benger's 
liquor, or Fairchild's pulverized extract may be used for mixing with 
the food. Weir Mitchell's method of administering cod-liver oil and 
pancreas is the best of all, if the patient can be got to take the 
trouble to use it, and it is an excellent plan where the oil cannot be 
tolerated by the stomach. Enough of water to cover 8 ounces of 
chopped beef pancreas is allowed to stand in a warm place for an hour. 
It is then squeezed through a towel, and 1 ounce of the juice is rubbed 
up with i ounce of pale cod-liver oil, and injected three times a day 
into the rectum. 

Lamb sweetbreads, which are cheap and easily procured, make one 
of the most palatable and nutritious dishes for the consumptive. They 
come in very well in the months when oysters are not to be had. They 
are best boiled for a few minutes in a very little water, and then stewed 
quickly in a saucepan with a small quantity of butter. 

The hypophosphites are believed by many to possess great efficacy 
in the early stages of phthisis, and the various quack syrups which are 
much used by the public are not without their therapeutic value; but, 
as a rule, those whose composition are known, when prepared by any 
respectable chemist, will be found to give more satisfactory results 
than the highly advertised nostrums. The syr. hypophosphitum comp. 
of the B. P. C. formulae is an excellent and reliable preparation, as is 
also Fellows' syrup. The quinine and strychnine may be omitted 
in the first- mentioned compound, when the effects of the hypophos- 
phites of iron, calcium-, manganese, and potassium only are desired. 
The U. S. P. syr. hypophosphitum may be used. 

When administered in conjunction with cod-liver oil, there can be 
no doubt that these drugs are most valuable in the early stages of phthisis 
and in very chronic cases. 

The treatment of pulmonary phthisis by drugs since the discovery of 
the bacillus of tubercle is one of ceaseless activity, and of incessant 
changes. Up to the present, unfortunately, little progress can be re- 



PHTHISIS. 647 

ported in the treatment of the disease by germicides, though every 
known substance whose action is inimical to the life of minute organ- 
isms has been administered. Of all these trials, by far the best results 
have been obtained by creasote. The writer has used it for several 
years past, and can testify to its great value in relieving cough, lessen- 
ing expectoration, lowering fever heat, checking night-sweats, and im- 
proving the appetite and digestion, and diminishing diarrhoea. As he 
never used it alone, but always in conjunction with all of the agents 
already mentioned, or as many of them as could be exhibited in each 
case, he cannot speak definitely about its specific or curative properties, 
but numerous observers testify to its specific action in phthisis. In 
basilar cavity in the lung, where decomposition of the sputum is evi- 
dent from the fetid odor of retained secretion, there is no remedy to 
equal full doses of creasote. In one case recently under the writer's 
care the most surprising results followed, and rapid healing of the 
cavity took place, but there was not evidence that the affection was 
tubercular. 

Many thousands of cases have been treated, especially in Germany 
and on the Continent, during the last few years, and the reports of Von 
Brunn, Guttmann, SahJi, Bourget, Szendiak, Kossow-Geronay, Wat- 
son, Seitz, Fawitzki, Nobili,Brzezinski, Sommerbrodt, Gimbert, Bouck- 
hardt, Flint, B. Robinson, Jaccoud, Frankel, Leech, Boganovitch, and 
hosts of other observers go, upon the whole, to prove that in creasote, 
when properly administered, we possess the best known drug for the 
treatment of phthisis. An examination of the reports of most of these 
observers will show that they have given much larger doses than are 
usually administered in this country, 10 to 20 grains daily being often 
administered for long periods. The writer has rarely exceeded 5 grains 
daily ; but it is his intention to push the drug, since the larger doses 
have been given with so much advantage, and without ill effects. 

Guttmann finds that the tubercular bacillus grows but feebly in a 
1 : 4000 culture with creasote, and he calculates that the ingestion of 
15 grains daily would charge the blood to this extent. It must be 
remembered that the bacilli probably are already struggling to main- 
tain an existence in the body against odds created by the vital agen- 
cies always exercising a hostile influence against intruders, and it is 
quite reasonable to expect that a small amount of a drug like creasote 
introduced into the system might, under such conditions, be able to 
turn the scale against the parasite. 

It is, however, a mistake to theorize too closely in a matter of this 
sort. It is just possible that the drug may exert no such influence in 
the body, but that all its beneficial action may be owing to its effects 
upon digestion, assimilation, or other vital functions which lead to a 
healthier or more resisting condition of the blood and tissues. It seems 
possible to the writer that the good effects of creasote may be owing to 
its causing such a change in the cells of the blood and lymphatic system 
as stimulates the natural progress of phagocytosis. (See under Tuber- 
culosis.) 



648 PHTHISIS. 

Many drugs introduced under totally erroneous theories have never- 
theless been found to accomplish the desired object, though in a very 
different way. The reports of the efficacy of the drug under considera- 
tion cannot be ignored, and there is fair ground for hoping that im- 
proved methods, whereby larger doses can be administered without evil, 
may give still better results. 

Pure beechwood creasote only should be used. This is now easily 
obtained in elegant small soft capsules, each containing one grain. 

Professor Robinson recommends, when ordering creasote, that the 
article manufactured by Morson or Merck should be specified. Many 
authorities object to the capsule on the ground that when it empties 
itself in the stomach a localized active inflammation must result. This 
is a mistake. As the capsule slowly dissolves, its contents gradually 
mix with those of the stomach ; and even when given fasting no harm 
can result, much less can injury be likely to follow when the capsule 
is given along with or after food. The writer has given these capsules 
very frequently in gastric affections and often in ulcer of the stomach, 
when no food had been taken for days, and he never saw the least 
irritation or other untoward result follow ; and he believes the capsular 
form to be by far the best method of administering the drug. It is 
unfortunately rather expensive, and for this reason outside hospital 
extern practice. 

The pilular form is generally most unsatisfactory, and a mixture 
containing the drug is most unpleasant. The following formula may 
be useful : 

K . — Creasoti purif. (Morson) . . - . Tljxxx. 

Spt. cinnamomi 3 iv. 

Tinct. aurantii amari ^ijss. 

Glycerini q. s. ad ^iv. — M. 

S. — One teaspoonful to be taken in a little water three times a day after meals, 
the bottle being shaken. 

Keferstein recommends — 20 grains creasote, 6 drachms alcohol, 6 
drachms syrup, and 3 ounces cinnamon water. 

Robinson uses — beechwood creasote, 6 minims ; glycerin, 1 ounce : 
whiskey, 2 ounces. 

Keferstein dissolves 45 minims in 1 ounce of tincture of cinnamon, 
of which 50 drops may be taken in half a cup of warm milk or a 
little wine. The formula for his pills is better ; they should be coated 
with gelatin : 

K . — Creasoti gr. lx. 

Pulv. althse rad. \ 

Pulv. glycyrrhiz. rad. i • oJ • 

Mucilag. acacise q. s. — M. 

Make a mass and divide into 120 pills. 



phthisis. 649 

Rosenthal highly recommends creasote to be given in carbonated 
water. 

Guaiacol is the chief therapeutic constituent of pure beechwood tar 
creasote, in which it sometimes exists to the extent of 90 per cent. 
Chemically it is the monomethyl ether of catechol or pyrocatechin, 
and is much less objectionable than creasote in taste and odor. It can 
be had in capsules, and sometimes may be tolerated when creasote 
disagrees. Sahli and Frankel have used it extensively in the treat- 
ment of phthisis with what may be regarded as very satisfactory 
results. It may be given in pill, mixture, or capsule. The usual 
method is in solution in some spirituous liquid or tincture, as in the 
case of creasote. Three minims is a fair dose, which may be elegantly 
administered in sherry or tincture of orange peel. The writer can 
only speak from a limited experience of the drug, but the literature 
of the subject is extensive and most encouraging. 

The internal administration of creasote may be easily carried out 
at the same time that cod-liver oil and hygienic measures are being 
used. Indeed, some physicians mix one minim of pure creasote with 
two drachms of the oil for administration three or four times a day, 
after meals, and double this quantity can often be taken without pro- 
ducing nausea or disgust. 

The creasote treatment is advantageously assisted by inhalations of 
the drug. These will be referred to later on in speaking of the 
administration of remedial agents by the respiratory tract. It has 
also been given subcutaneously. 

Bourget carries out the creasote treatment to the fullest extent by 
what is known as the " intensive method." By this plan the patient's 
system is saturated with the drug through various channels. Thus, 
guaiacol is given by the mouth, dissolved in wine in summer and in cod- 
liver oil in w T inter, until about 1 gramme (15 grains) daily is gradually 
reached. Where it causes nausea, and sometimes even when it is well 
borne, he alternates the mouth method with that of rectal injections. 
At the same time every night a mixture of creasote and cod-liver oil 
(1 : 10) is rubbed into the skin over the chest and armpits and abdo- 
men, while as often as possible during day and night creasote is 
sprinkled upon an inhaler. 

Recently Picot, of Bordeaux has obtained very striking results by 
the hypodermic injection of from 1 to 3 cubic centimetres into the 
supraspinous fossae, of a mixture of guaiacol and iodoform in sterilized 
olive oil and vaseline. Each cubic centimetre of the fluid which is 
transparent and bright contains 1 centigramme of iodoform and 5 
centigrammes of guaiacol. Sweating and fall of temperature follows 
each dose, but the reaction is not marked. Iodide of potassium 
appears in the urine. 

He reports that he has seen no such improvement after the use 
of any other drug. The general condition improves, cough and 
expectoration are lessened, while cavities dry up and cicatrize. In the 

42 



650 PHTHISIS. 

later stages of phthisis cough and expectoration are also lessened, 
while night-sweats and fever may disappear, and the number of the 
bacilli in the sputum undergoes diminution. 

Sulphur in various forms has been long employed as an anti-phthisi- 
cal agent, and since the discovery of the bacillus it has again come 
to the front in many new methods. The old plan consisted in the 
administration of the crude drug by the mouth, or by the administra- 
tion of any of the sulphur waters, and a residence at some of the 
natural sulphur springs was considered and is still considered to be 
highly efficacious. Sulphur is an excellent expectorant, and is partly 
excreted by the bronchial mucous membrane. The writer has long 
praised the onion (which contains much sillphur) as one of the best 
known expectorants. Sulphur seems, to some extent, to fulfill Brun- 
ton's ideal of a substance which should be looked for, and which 
would undergo slow decomposition in the intestine, or in the body 
generally, and give off slowly and constantly volatile antiseptic pro- 
ducts to be excreted by the lungs. 

Hitherto it has not been administered in such a way as to give hope- 
ful results, though Witherle believes he has influenced the disease by 
giving small doses of the sulphide of calcium (J grain in pill) every 
hour until the system is saturated. 

The apparently barbarous method of Bergeon, by which large 
quantities of sulphuretted hydrogen diluted with carbon dioxide, are 
administered by the bowel, can hardly be said to be making much 
headway. He uses a caoutchouc bag of the capacity of about one 
gallon. This is filled with C0 2 , and connected with a Wolffe's bottle, 
which is attached to a tube and nozzle for introduction into the 
rectum. 

The Wolffe's bottle being filled with a natural sulphuretted water, 
the compression of the bag causes the C0 2 to bubble through the sul- 
phuretted water and pass on into the intestine of the patient. Ten 
ounces of the water was used, and the entire contents of the bag were 
made to pass through this and enter the bowel at each sitting twice 
daily. There is much question about the real agent in producing the 
amelioration in the patient's symptoms — for amelioration as regards 
fever, cough, appetite, expectoration, and emaciation does occur. 

Some observers, among whom is Dupont, affirm that it is the C0 2 
which is the active agent, though Beaumetz states it is the sulphuretted 
hydrogen, notwithstanding that Wood maintains that there is no evi- 
dence that this agent has any toxic effect upon disease germs. 

Bardet's method of using the H 2 S injections is different. He uses a 
solution containing 10 grammes of calcium sulphide in 100 cubic cen- 
timetres of distilled water. One cubic centimetre of this solution sets 
free 10 cubic centimetres of H 2 S when treated with an acid solution 
consisting of 25 grammes of tartaric acid and 1 gramme of salicylic 
acid in 100 cubic centimetres of water. 

One cubic centimetre of the acid solution displaces the H 3 S of 1 cubic 



PHTHISIS. 651 

centimetre of the sulphide solution, and thus the amount injected is 
easily calculated. 

Wood's suggestion that rectal injections of sulphuretted' hydrogen 
water should be used instead of the gaseous injections is a. good 
one. 

The writer, without any personal experience of the gaseous injec- 
tions, after wading through the voluminous and contradictory reports 
of this method as practised by numerous experimenters, is perfectly 
satisfied that equally valuable and more constant results can be 
obtained by the administration of natural sulphur waters by the 
mouth. 

Sulphites and hyposulphites, with inhalations of sulphurous acid, 
have been used upon the same principles. 

Bergeon now advocates rectal injections of C0 2 , and others give a 
bicarbonate by the mouth, followed by an acid soon afterward in 
order to disengage CO., in the stomach. This is excreted by the 
pulmonary tract, and is supposed to improve the pulmonary nutrition, 
and increase the perimeter of the chest, and destroy the bacilli. 

Arsenic has been fairly tried in phthisis, and some glowing reports 
of its value have been furnished from time to time. It is very dif- 
ficult, however, to be # certain that these good results have not been 
partly or mainly owing to the hygienic measures which were generally 
employed at the same time. 

Brunton believes that by increasing the tissue changes in the 
epithelial contents of the alveoli it assists in rapidly breaking up 
and removing effused inflammatory products, and so prevents the 
tubercular bacillus from finding a suitable nidus, and thus the risk 
of converting a catarrhal consolidation into phthisis is prevented. 
It is only in the early stages of phthisis that the remedy is likely to 
do any permanent good, and notwithstanding the reports of decided 
successes, its administration should not be allowed to interfere with 
the exhibition of the more important hygienic measures already 
enumerated. In the later stages it sometimes checks the night sweats, 
and seems to have some effect upon the temperature w 7 hen this is not 
of a very high type. Some suppose that it benefits the sweating 
when this is depending upon or associated with a subfebrile tem- 
perature. 

Upon the same principles as are supposed to constitute arsenic a 
suitable anti-phthisical remedy mercury has been employed, and some 
sanguine therapeutists believe that in this direction lies the hope of the 
ultimate victory over the bacillus of tubercle. The dread of the evils 
attending the administration of mercury is no doubt greatly exagger- 
ated, and the writer has seen tonic effects as well as gain in weight 
and vigor, and improvement in the physical signs in catarrhal con- 
solidation after the administration of small doses of the bichloride of 
mercury. 

Dochmann maintains that administered in the first and at the 



652 PHTHISIS. 

beginning of the second stage, calomel improves the appetite, dimin- 
ishes cough and fever, and dispels night sweats. Later on it reduces 
the fever, checks diarrhoea and improves the general condition. Bin- 
iodide of mercury in y 1 ^ grain doses has been also highly recom- 
mended, and in the form of pulverizations it has been used with the 
view of reaching the bacillus directly. The bichloride has been used 
in a similar way in the spray form, and these remedies have also been 
employed for parenchymatous injections. 

Martel insists upon the great value of insufflations of calomel. 

Notwithstanding reports, there is upon the whole, little encourage- 
ment to be obtained from the experiences of the routine administration 
of mercurials in phthisis with our present methods. 

Eucalyptus oil, thymol, menthol, myrtol, salol, aristol, oil of cloves, 
naphthol, balsam of Peru, aniline, ozone, oxygen, peroxide of hydro- 
gen, carbolic acid, phenyl-propionic and phenyl-acetic acids, mullein, 
homeriana, helenin, sulphocarbolates, benzoic acid, chloride of calcium, 
chaulmoogra oil, terebene, chloride of sodium, salicylic acid, iodoform, 
turpentine, iodides, and tannin, have each one lately been reported by 
different observers as having special or specific action upon the bacilli 
when administered internally. Except the last remedy nothing need 
be said of the efficacy of these agents, their virtues as anti-phthisical 
remedies will require much stronger evidence in their favor than is 
at present available. Tannin has numerous patrons, and any one 
perusing the many glowing reports about the efficacy of this drug in 
phthisis, without allowing the usual discount for enthusiasm, would be 
forced to conclude that the difficulty of curing the disease was solved. 
The writer has given it a trial in some cases with negative results. 
Houze gave 15 grains three times a day to all the phthisical patients 
in a Brussels hospital " with excellent results " in all stages of the 
disease, especially when cavities existed. The balsam of Peru, already 
mentioned, has occupied the attention of Schnitzler, who finds that if 
injected into the veins it has a very decidedly curative action. He, 
therefore, has discarded its administration by the mouth, and gives it 
by the hypodermic needle in the form of an emulsion with oil and 
mucilage. It will require many more tempting reports before this 
method will become a recognized treatment for phthisis. 

Great activity has been shown of late in the treatment of pulmonary 
phthisis by methods which are intended to bring the antiseptic or anti- 
parasitic agents into direct contact with the diseased spots with their 
contained bacilli. Inhalations, sprays, insufflations, and parenchy- 
matous injections have been tried; but taking all the reports into 
consideration, though marked temporary improvements have been often 
recorded, the general results have been disappointing. A few of the 
more important methods will be briefly summarized. 

The inhalation of dry hot air has been tried with the view of destroy- 
ing the bacillus. Renzi uses air at a temperature of 350° F. Others 
have tried very cold : air; the results are most disappointing. (The 



PHTHISIS. 653 

latter method promises well for haemoptysis, the former method seems 
to induce it. Moist warm air has also been used. Dujardin-Beaumetz 
and others denounce these methods as worthless and positively danger- 
ous, and they may be regarded as now unjustifiable. 

Hydrofluoric acid has been much used and some good results have 
been obtained, but others have denied that it has had any beneficial 
effects, so that it is needless to describe the method which is carried out 
by placing the patient in a chamber into which acidified air is pumped 
until each cubic metre contains ten to twenty litres of the fumes ob- 
tained by acting upon fluorspar with B^SO^ in a leaden vessel. It 
does not appear that any harm can result from this treatment, and 
gains of fourteen and sixteen pounds have been recorded after two 
months' treatment of one hour each day. 

Creasote has been given by inhalation as already mentioned with 
much benefit, but the method of treating phthisis with antiseptic 
respirators, which had such a rage after the discovery of the bacillus, 
is certainly losing ground, and except as an adjunct to other treatment 
when special complications exist it will cease to be used. 

The perforated zinc inhaler, used with persevering care in conjunc- 
tion with the internal and external or "intensive" method of adminis- 
tering creosote, has given decidedly beneficial results, but how much 
of the good is owing to the other means of getting the drug into the 
system is hard to say. Where the fetor of the expectoration is marked 
there cannot be a doubt that this treatment is most beneficial. A few 
drops (15 minims) of a solution of creasote in alcohol (1 in 3 or 4) may 
be sprinkled upon the sponge several times during the day. 

Thymol, guaiacol, iodine, carbolic acid, eucalyptus, iodoform, 
menthol, and various other volatile antiseptics have been used in this 
way with varying successes. 

Eobinson's inhaler liquid consists of — 



J&. — Iodoformi 

Creasoti purif. . 
01. eucalypti . 
Chlorofornii 
Aleoholis et setheris 



ST. XXIV. 



■ mviij. 
• mxiviij. 

ad ^ iv. — M. 



Coghill's liquid consists of — 

H. — Creasoti purif. . .' ^j. 

Acidi carbolici gij. 

Tinct. iod ^ij. 

Spt. vini rect giij. — M. 

Iodide of mercury — 1 part of iodide of mercury and 1 part iodide of 
potassium in (5000 to 15,000) water — to be used as a spray, has been 
extolled as a bacillus exterminator. It has been used in solution of 
five to ten times this strength. 



654 PHTHISIS. 

It is, however, exceedingly doubtful if any of the above solutions 
ever reach the bacilli in the lung tissue, but it is almost certain that a 
portion of the dose finds its way into the circulation eventually. 

Compressed air is recommended by Forlanini, and oxygen and ozone 
have been tried, and even nitrogen, diluted with twice as much air, 
has been administered by Valenzuela, who finds the effects the same 
as if rarefied air was used, a marked antipyretic action being always 
observable. 

Germain See has recently conducted extensive experiments upon the 
treatment of phthisis by artificial or medicated atmospheres under 
pressure, and he reports improvement of appetite, gain of weight, 
diminution of cough and expectoration, and subsidence of fever. His 
method is carried out by placing the patient in a close chamber for 
one, two, or three hours, into which air was forced at an increased 
pressure of about half an atmosphere, after passing through a solution 
of creasote and eucalyptol. 

The oil of pinus pumilio is of great benefit in some cases as a spray 
or inhalation, or sprinkled over the sponge of an inhaler or respirator. 

Parenchymatous or intra-pulmonary. injections have been tried in a 
great number of cases during the past few years, and sometimes with 
partial success, and sometimes with evil results. . 

Fernet injects, by a long needle connected with a Pravaz syringe, 
3 drops of camphorated naphthol (equal 1 of pure naphthol). 

Riva injects into different parts of the lung at one time more than 
1 ounce of a 1 : 3000 corrosive sublimate solution. The biniodide is 
used in the same way, and nearly every known antiseptic has been 
tried, especially creasote dissolved in eucalyptus oil or liquid vaseline. 

Iodoform or iodol are favorite drugs for this purpose, but the writer 
is content to. wait for further evidence of their value before adopting 
this plan. 

D. Walker injects a solution of menthol (12 per cent.) and creasote 
(2 per cent.) in olive oil into the larynx by passing a curved vulcanite 
tube through the vocal cords. He reports the usual glowing improve- 
ments in early phthisis — i. e., loss of cough and gain in weight — from 
this practice. 

Recently Lannelongue's plan of attacking the bacilli by deep injec- 
tions of the chloride of zinc has received close attention. (See under 
Tuberculosis.) 

There would appear to be no limit to the daring of some thera- 
peutists. An American physician reports that, observing the absence 
of phthisis in rheumatic patients, he injected 6 ounces of blood from a 
rheumatic patient into persons suffering from phthisis. Rheumatism 
was said to have followed, with great improvement in all the chest 
symptoms. 

Little need be said of the various suggested surgical procedures, as 
the tapping, washing out, and draining of cavities, or the opening freely 
into them by bold and free incisions from without, with the view of 



PHTHISIS. 655 

applying the cautery or caustics. Such practice must show very dif- 
ferent results from those published before interference of this kind 
comes to be recognized as a justifiable routine treatment in phthisis. 
The surgical treatment of large superficial basilar cavities is a legiti- 
mate undertaking in many cases. 

Very receutly Tuffier, having satisfied himself that the ordinary 
surgical procedures limited to the opening and drainage of large tuber- 
cular cavities did not exhaust the resources of the operator, was tempted 
to try resection of the lung in incipient phthisis. He made an incision 
into the second intercostal space, passed his finger over the apex of the 
lung, found in it a nodule the size of a large hazel-nut, and, after 
drawing the apex of the lung through the wound, he applied to it a 
silk ligature tightly, and cut off the diseased portion, suturing the 
pedicle accurately to the periosteum of the internal surface of the 
second rib to prevent the danger of pneumothorax. Rapid recovery 
followed, all dressings being dispensed with upon the ninth day. 

The surprising results obtained by surgical treatment in tuberculosis 
of the peritoneum are noticed under Peritonitis, on page 611. 

Koch's method of treating pulmonary phthisis, which has been tried 
during the past year, is not referred to in this article. The writer has 
reserved for it a place under the heading of Tuberculosis, which should 
be read in connection with the present. In that place he ventures to 
insert a plea for the further trial of the lymph under different dosage 
regulations, and to protest against the abandonment without further 
trials of an agent proved to possess such marvellous selective action. 

Cantharidinate of potassium, the injection of dog's serum and goat's 
blood, and other new agents, are also mentioned under Tuberculosis. 

Remedial agents for the treatment or relief of some of the more 
prominent symptoms of phthisis may be mentioned. Cough demands 
attention in most cases at some stage or other of the affection, but there 
can scarcely be instanced a greater mistake in medical practice than 
the routine treatment of pulmonary consumption by cough mixtures. 
The use of the various expectorants and anodynes which unfortunately 
constitute the chief portion of the anti-phthisical armamentarium of 
some physicians only leads to destruction of appetite, injury of diges- 
tion, increase of sweating, and all the numerous ills resulting from 
retained secretion. 

In the early stages of phthisis where the incessant, hard, dry, hacking 
cough interferes with the patient's rest and assists in keeping up the 
irritation and fever, it is the duty of the physician to administer ano- 
dynes in small and oft-repeated doses so as to slightly influence the 
respiratory centre and check coughing, which is as injurious as it is 
useless. The saline mixture mentioned upon page 646 will be found 
to meet the case, and the quantity of morphine may be doubled, and 
an additional drop of dilute hydrocyanic acid maybe often added with 
advantage to each dose. Mixtures of this sort should be given very 
sparingly through the day, but they may be administered more freely 



656 PHTHISIS. 

during the night. The citrate of potassium formed on adding the lemon 
juice to the alkali is a valuable expectorant, and where the mucus is 
tenacious in cases characterized by difficult expectoration, ammonium 
carbonate to about half the amount of the potassium salt may be sub- 
stituted. 

A teaspoonful of sal volatile in a wineglassful of water, to which a 
tablespoonful of fresh lemon j uice and y 1 ^ grain of morphine have been 
added, is always a perfectly safe combination, and in the dyspnoea of 
the cavernous stage it may be given to great advantage if the morphine 
be omitted. 

Iodide of potassium with small doses of ipecacuanha -wine may be 
tried after meals. 

The various remedies already mentioned as valuable in the constitu- 
tional treatment of the disease will be found of great benefit to the 
cough. Thus, cod-liver oil often relieves it, and creasote is frequently 
very efficacious at all stages of the affection. Tar and creolin act in 
the same way. Counter-irritation by small blisters or iodine or Chili 
paste often helps the cough. 

The various inhalations already mentioned may be tried. Indeed, 
as a rule, everything or every method should be preferred which will 
give relief to cough without drugging by morphine, chloral, henbane, 
hemlock, bromides, etc. 

Creasote inhalation, as already mentioned, is indicated especially in 
basilar cavities, or where expectoration is profuse and fetid. 

The pinus pumilio is a grateful and efficacious remedy. 

Conium with hydrocyanic acid often acts speedily in subduing spas- 
modic cough w T hen administered in the form of an inhalation. 

When the cough is accompanied by pain, or where from pleuritis or 
pleurodynia each deep inspiration is painful, anodyne liniments, as 
chloroform and belladonna may be applied under oiled silk or upon 
spongio-piline, but, as a rule, there is nothing to give the relief which 
is afforded by fixing the chest wall at the affected spot. 

While writing the present article, the writer has been called to re- 
lieve a patient in the last stages of the disease, in whom every attempt 
at coughing was followed by a stabbing, agonizing pain in the chest. 
Relief was instantly obtained by strapping the affected side of the 
thorax by long strips of adhesive plaster, passed from the sternal region 
of the sound side round the pained ribs, and catching firmly upon the 
opposite side of the vertebral column, so as to immovably fix the 
affected pleura as in a vice after the method suggested by Roberts. 

Poulticing, as a rule, is of little use in such cases, but in local in- 
flammatory complications of superficial extent, it may be often utilized 
with great advantage for short periods. 

Fever or pyrexia is one of the most serious symptoms which the 
physician will be called upon to contend with in the course of phthisis. 
Up until comparatively recently he had to content himself with look- 
ing on while the patient slowly or quickly burned himself out. Too 



PHTHISIS. 657 

often the suffering of the phthisical victim will be found to be meas- 
ured by his increased temperature, and if this can be reduced and 
kept within bounds by safe measures, much of the pain, distress, and 
indescribable weariness which characterize some examples of the dis- 
ease may be obviated. Quinine is most unreliable, and in doses of 
large amount often aggravates the patient's discomfort by the unpleas- 
ant symptoms of cinchonism, or by the still more undesirable effect of 
drying up his expectoration and increasing his cough. 

The new antipyretics — antipyrine and antifebrin — are blessings of 
great value in tne treatment of the pyrexia of some cases of phthisis. 
The method which was at first pursued after the introduction of anti- 
pyrine was carried out by the writer for three years. It consisted in 
administering 30 grains of antipyrine, and in one hour giving 15 grains 
more, and in another hour 15 grains again (60 grains in all), if the 
temperature had not fallen after the first or second dose. Sometimes 
a drop of 10° F. was observed, and the temperature was often found 
not to rise for twenty-four hours after, during which time the greatest 
relief was experienced of all the distressing symptoms of the disease. 

Though the writer never witnessed any alarming results from this 
large dose in phthisis, other observers have recorded serious collapse 
and cyanosis, symptoms which he has since observed when small doses 
have been given in other affections. 

These untoward effects have led to the drug being administered in 
smaller doses at frequent intervals, 10 grains being given every four, 
five, or six hours until the temperature falls. Though the results by 
this plan are not nearly so definite and satisfactory as when the one 
large daily dose (60 grains) is given, still, upon the whole, it is more 
likely to be safer, and hence the older plan is being gradually replaced 
by the small dose system. Some physicians content themselves by 
giving a 5 grain tablet every few hours until the temperature begins 
to fall. The rise in this case soon follows, and the thermometer must 
be used often, as the physician feels his way and takes soundings before 
administering further doses of the drug. 

Antifebrin may be given in 4 grain doses every four or six hours. 
It yet remains to be proved that it is safer than antipyrine, and though 
it will scarcely produce the same certain and speedy fall as is almost in- 
variably found after a very large dose of this latter drug, nevertheless, 
it appears to have a steadier and more continuous action when given 
on the small dose system, consequently it will probably be found to 
better serve the end which the physician has in view in the reduction 
of fever heat in phthisis. It is also much cheaper. 

It is needless to discuss the advantages of these remedies. Though 
they in no way tend to affect the ultimate end to which the diseased 
action is slowly or quickly progressing, any one who watches the ease 
and comfort so frequently following their administration will not with- 
hold them in every case of phthisis. The drawback most likely to 
cause inconvenience will be excessive perspiration, and in very ad- 



658 PHTHISIS. 

vanced stages of the disease, in very weak patients, they should be 
given cautiously, and in very small doses; 2 } grains of antifebrin 
often give relief under such circumstances. Other new antipyretics 
need not be discussed. Since using antipyrine, the writer has never 
had to employ sponging or to give wet packs for the high temperatures 
of acute or chronic tuberculosis. 

These new agents, it must be remembered, are not suitable remedies 
to be used in a purely routine manner in the treatment of every rise of 
temperature in chronic phthisis. 

Williams does not speak highly of them, and when an agent for the 
relief of high temperature is needed, he prefers quinine and salicylates. 
For the pyrexia of the first stages of tuberculosis, he prefers derivate 
measures, such as counter-irritation and salines. 

Where the temperature, however, rises to a height bordering upon 
hyperpyrexia, in the opinion of the writer, these agents are of little 
value, and the judicious administration of antipyrine is the best and 
safest agent available. 

Hemoptysis occurring during the course of phthisis will be met by 
remedies mentioned upon page 311. ■ 

Diarrhoea. Under this heading, upon page 190, the various reme- 
dial measures useful in the treatment of different kinds of diarrhoea 
have been enumerated. 

There is no special or specific astringent for phthisical diarrhoea. 
When ulceration of the intestines exists, opium or morphine is indi- 
cated, in doses sufficient to quiet peristalsis and relieve pain, and occa- 
sionally lead or copper salts may be also indicated, but where a pure 
astringent action is desired in*the chronic diarrhoea of phthisis, the 
writer avoids the matallic astringents, and selects hsematoxylon as the 
least objectionable and most efficacious remedy of this class. It may 
be given in pill, powder, or mixture, 10 to 15 grains of the dry pow- 
dered extract being a moderate dose. Every known astringent and 
antiseptic remedy has been tried and generally found of some use. 

Beta-naphthol, hydro -naphthol, and small doses of hydrarg. bichlor. 
are advocated. 

One creasote capsule after each motion sometimes acts like a charm. 

Lactic acid has recently been found of greatest service by some 
observers, and talc is used by others. (See under Diarrhoea, page 189.) 

Under Peritonitis will be detailed the recent extraordinary results of 
treating abdominal tuberculosis by laparotomy. 

Night sweating. The old-fashioned pill is still regarded as one of 
the best remedies. It may be given at bed-time, or oftener if required. 

B . — Zinci oxidi gr. iijss. 

Ext. belladonnse . gr. £. 

Ext. hyoscyami . . . . . . . gr. ijss. — M. 

Make twenty-four of these. 

S. — One pill to be taken at bed-hour. 



PHTHISIS. 659 

Belladonna or atropine seldom fails to relieve the sweating, but the 
dryness of the throat and the effects upon the expectoration and the 
heart often prevent its being used in such doses as give reliable results. 
One minim of the solution of atropiue (1 : 100), representing -j-J-g- grain, 
very generally checks sweating in phthisis, or 10 minims of the tinc- 
ture of belladonna may be given in the evening, and 3 minims every 
two, three, or four hours afterward, may be safely administered. Occa- 
sionally belladonna and atropine fail. 

Agaricine possesses very marked influence in checking the night 
sweats of phthisis, as first pointed out by Murrell. No disadvantages 
follow its action, and in some cases it affords relief when every other 
drug fails. There is much confusion about the dose, as the different 
samples of the drug differ considerably in strength. One-eighth grain 
of the white crystalline powder may be given every four hours in very 
severe cases. Often one dose acts like magic, and repetition may not 
be needed for a considerable time. 

It may be given alone, in aromatic sulphuric acid, or with Dover's 
powder. 

Klemperer gives -J- grain of agaric acid in pill in the early evening. 

Hyoscine in minute doses, yl-g- grain, hypodermically, gives good 
results. 

Dover's powder in 1 grain doses is used by some, but it is very un- 
certain. 

Picrotoxin, \-1-q grain, often acts most beneficially, and strychnine 
occasionally succeeds. 

Quinine in 3 to 6 grain doses may be tried. 

Arsenic in small repeated doses occasionally answers well. 

Muscarin, \ grain, hypodermically, checks phthisical sweating, and 
it may be also given by the mouth. 

Sul phonal, in addition to its hypnotic properties, may be very often 
found to give excellent results in this complication. The writer has 
used it with great satisfaction in doses of 6 to 8 grains, but in one very 
advanced case at present under his notice it has not only failed, but 
the patient insists that upon every occasion of its administration the 
sweating becomes more profuse and exhausting. This is, however, a 
most exceptional result. 

Phosphate of calcium in 8 to 12 grain doses has sometimes given 
good results, as it may check both sweating and diarrhoea. 

Tannic and gallic acids, sulphuric acid, sulphate of iron, ergot, 
alum, and many other drugs have sometimes proved useful. 

Tellurate of sodium, in doses of I grain, in pill, once a day, has re- 
cently given excellent results, but the most objectionable garlic odor 
given to the breath is a barrier to its use. 

Sponging the body over with vinegar or vinegar and w T ater generally 
affords some relief, and belladonna may be used in the same way with 
advantage. Chloral, 2 drachms, dissolved in a tumblerful of brandy 
and water, has been found very useful when sponged over the body. 



660 PITYRIASIS RUBRA. 

Very hot water often acts promptly when used in the same way, as 
does solution of alum. 

Rossenbach reports encouraging success after the application of an 
ice-bag over the abdomen for several hours during the night, in cases 
where other remedies fail. 

Laryngeal symptoms are to be met by the remedies mentioned upon 
page 440 for laryngeal phthisis. 

Peritoneal complications are referred to under the treatment of 
Tubercular Peritonitis, on page 611. 

PITYRIASIS RUBRA OR EXFOLIATIVE DERMATITIS. 

The treatment of this very formidable affection is not so hopeless as 
Hebra's opinion would lead one to expect, the writer in a limited ex- 
perience having seen at least three cases, closely agreeing with Hebra's 
description of the disease, which completely recovered under appro- 
priate treatment. Internal remedies do not appear to exercise much 
influence, and in the successful cases it is very doubtful if they have 
contributed much to the result. ' After trying most of the reputed 
remedial agents, the writer is inclined to believe that if any good is be 
obtained from drugs internally it will be furnished by small doses of 
arsenic in combination with a diaphoretic and diuretic, as in the fol- 
lowing : 

R. — Liq. amnion, acetat ^iij. 

Potassii acetatis . . . . . . . sjij. 

Liq. Fowleri ITLxxxv. 

Aquae camph. ...... ad t fx. — -M. 

S. — A tablespoonful after meals three times daily, in water. 

Cod-liver oil and iron at a later stage are also probably useful. 

Local treatment will undoubtedly do much if conscientiously and 
patiently carried out, the chief indication being to protect the affected 
part (the entire cutaneous covering of the body) from the irritation 
produced by contact with the air and variations in temperature. 
Special symptoms will call for endless modifications of details. A 
weak alkaline bath, containing starch or a little carbolic acid, may be 
permitted for one or two hours daily where itching is very trouble- 
some. Most reliance is to be placed in inunctions by an animal or 
vegetable fat. These should be carried out several times daily by an 
experienced hospital nurse told off for the purpose. Fresh lard, 
deprived of every trace of saline matter, answers the purpose well. 
About 2 ounces of the simple liniment of camphor may be added to 
each pound of the fat, and in summer suet may be also added. This 
may be rubbed in gently and patiently, after the scales have been 
removed by prolonged immersion in the warm bath or by very gentle 
friction with a soft, rough cotton towel. Zinc ointment, to which 5 or 
10 per cent, of the camphorated oil has been added, is to be then 



PITYRIASIS VERSICOLOR — PLACENTA PREVIA. 661 

smeared over the limbs, which should be covered with lint or old 
linen, also well coated over with the ointment, and comfortably band- 
aged ; the body being several times annointed with the lard during 
the day, while the limbs and face need be only dressed morning and 
night with the ointment. Cod-liver oil, and olive or almond oils, may 
be also used. Some cases have been successfully treated by causing 
the patient to live in a warm bath for many days or even weeks at a 
time. 

PITYRIASIS VERSICOLOR. 

Pityriasis versicolor, being a harmless parasitic affection,' only slightly, 
if at all, contagious, its treatment is seldom demanded by the patient, 
who, as a rule, is scarcely conscious of its existence. 

Almost any parasitic remedy speedily removes the discoloration, and 
the physician can use any antiseptic solution which pleases his fancy. 
The most elegant will be : 

R . — Hydrarg. chlor. corros. gr. xr. 

Amnion, clilor . gr. xv. 

Spt. lavandulse ^yj. 

Mist, amygdalae ...... ad ^x. — M. 

S. — To be freely sponged over the discolored spots every night. 

Carbolic lotion or a strong carbolic soap will remove it. In phthisical 
patients the affection is common, and is sometimes entirely removed 
by the application of iodine which is used for purposes of counter- 
irritation, or by eucalyptus or creasote ointments applied with other 
objects in view. 

Sulphites, or sulphides, or sulphurous acid solution (1 : 5), are 
speedy and cleanly. 

PLACENTA PRJEVIA. 

Though a description of the various operative measures which may 
be demanded at the puerperal period is outside the scope of the present 
volume, a brief reference to the treatment of this formidable abnormal 
condition may be here inserted. 

The management of the case will depend, to a very large extent, 
upon the term of the pregnancy, duration, and extent of hemor- 
rhage, etc. 

In the earlier months (before the seventh), where the hemorrhage 
calls attention to the condition and the diagnosis is clear, the treat- 
ment of the case will be pretty much like that of an abortion. Abso- 
lute rest upon a hard bed in a cool room, with the usual precautions 
indicated under Abortion, may tide the patient over the period when 
the viability of the child may be naturally expected. This expectant 
plan is, however, only justifiable when the hemorrhage is very small, 



662 PLACENTA PREVIA. 

and the onset of severe bleeding, which may demand immediate action, 
is always to be arranged for. , 

When this profuse hemorrhage occurs, the rule should be observed 
that delivery is to be accomplished at the earliest possible moment. 
If the os be small and not dilated to any considerable extent, not- 
withstanding the adverse opinion of many authorities, the practioner is 
justified, if the waters have not come away, in carefully plugging the 
vagina by the method mentioned upon page 11. This as a temporary 
expedient will serve many purposes. It will stop the hemorrhage for 
a time, during which the physician can arrange for the assistance 
which he requires. It will in some cases enable -him to put an 
exhausted and ansemic patient into a better condition to bear the 
shock of a rapid delivery, and it will probably excite the uterus to 
better contraction. Spiegelberg disapproves of the method of plug- 
ging by rubber bags in this condition, and he advises the introduction, 
of a disinfected sponge or a laminaria tent before inserting the vaginal 
tampons, " if the cervix be far from dilated." He objects to the plan 
of Hick's version being employed when the cervix is unprepared for 
it. The same objection also maintains against rupturing the mem- 
branes under similar circumstances. If the os is already dilated to any 
extent when the patient comes under notice, or if the os is found 
dilated after the removal of the plugs, the course is then the same in 
both cases, and does not admit of any question. It is to turn and 
deliver as quickly as possible. The operator introduces his hand 
through the os by the side of and not through the placenta, proceeding 
in the direction in which he feels the adhesions to be the least exten- 
sive, avoiding, as far as possible, rupture of the membranes as he car- 
ries his hand high up into the uterus between its wall and the mem- 
branes, until the feet are grasped and brought down, when delivery 
may be accomplished in the ordinary way. The extent of the hemor- 
rhage must not be permitted for a moment to paralyze or unduly 
hasten the operator's efforts. With the feet grasped in the uterus, the 
forearm of the physician acts as a plug, and generally stops the hemor- 
rhage; and at this moment he may safely rest for a brief period before 
proceeding further, so as to be prepared for the gush of blood which 
generally accompanies the descent of his hand and arm. 

Obermann lays stress upon the importance of massage of the body 
of the uterus during the process of extraction, which should be most 
deliberate. 

The following rules are laid down by Braxton Hicks for the manage- 
ment of placenta prsevia, and are of such importance as to warrant 
their reproduction here : 

1. After diagnosis of placenta prsevia is made, proceed as early as 
possible to terminate pregnancy. 

2. When once we have commenced to act, we are to remain by our 
patient. 

3. If the os be fully expanded and the placenta marginal, we 



PLEURITIS, ACUTE. 663 

rupture the membranes and wait to see if the head is soon pushed by 
the pains into the os. 

4. If there be any slowness or hesitation in this respect, then employ 
forceps or version. 

5. If the os be small and placenta more or less over it, the placenta 
is to be carefully detached from around the os. If no further bleeding 
occur, we may elect to wait an hour or two, but should the os not 
expand, and if dilating bags are at hand, the os may be dilated. If it 
appears the forceps can be admitted easily, they may be used, but if 
not, version by combined external and internal method should be 
employed, and the os plugged by the leg or breech of the foetus ; after 
this is done, the case may be left to nature, with gentle assistance, as in 
footling and breech cases. 

6. If the os be small, and if we have neither forceps nor dilating 
bags, then combined version should be resorted to, leaving the rest to 
nature, gently assisted. 

7. If during any of the above manoeuvres, sharp bleeding should 
come, it is best to turn by the combined method in order to plug with 
the breech. 

8. Where the .hemorrhage occurs before the end of the seventh 
month, version by the combined method, no force following, is the 
best plan. 

To these I may add, however, if we employ a routine method in all 
cases, it will be found that the version by combined method, on force 
following, gives a result as good, if not better, than any. The after- 
treatment must be conducted on modern principles. Should oozing 
occur after the expulsion of the placenta, the swabbing of the lower 
uterus by styptics will be easy ; and inasmuch as the outlet of the 
uterus is liable more especially to be blocked by adherent clots, it will 
be wise to irrigate the cavity daily with some antiseptic solution, or to 
insert iodoform pessaries into the vagina, particularly if the irrigation 
cannot be done. 

PLEURITIS, Acute. 

Acute inflammation of the pleura is to be met by the measures 
already pointed out as beneficial in the treatment of other inflamma- 
tions. The most prominent symptom, and the one calling out most 
loudly for relief, is pain. This should be promptly met by morphine 
or opium, and these agents act beneficially in other ways than simply 
by giving relief to the patient's suffering. If the case is seen from the 
first onset of the disease, when the pain in respiration or in coughing 
is very severe, a hypodermic injection of i grain of morphine may be 
administered in the region of the pained pleura. This may not be 
repeated unless under exceptional circumstances, as the best effects of 
opium in the inflammation of serous membranes will be obtained by 
oft-repeated small doses by the mouth. With the opium should be 
combined remedies which will have some effect in subduing the fever, 



664: 

by acting upon the skin and quieting the circulation. Even at the 
very onset the writer has used the new antipyretics with great benefit 
where the constitutional disturbance and fever heat chanced to be very 
high. This, however, is not frequently the case, and the best routine 
treatment at this stage will be found in a simple diaphoretic combined 
with the anodyne, as in the following : 

R. — Morphine hydrochlor. . gr. j. 

Tinct. veratri vir TTLviij. 

Liq. ammon. acetat. . Jfijss. 

Vin. antimonii . . . . . . . . 3 ijss. 

Aquae camph. ad ^viij. — M. 

S. — One tablespoonful to be taken every third hour. 

The exhibition of opium is not the only measure to be relied upon 
for the relief of pain. 

General blood-letting is unfortunately now seldom used. In severe 
cases it may save life, and anyone who, like the writer, has seen it 
afford marked and speedy relief with amelioration of every symptom 
will not readily be seduced into the present prevailing belief in its 
inefficacy. When the urgency of the pain and dyspnoea warrant the 
letting out of blood, a large opening should be made in a fair sized 
vein, 12 ounces, or even a pint of blood, may be allowed to freely flow, 
and instant relief may follow. 

Leeching, though acknowledged to be less efficacious, is much more 
frequently practised. Ten leeches may be placed over the affected 
side, and if the patient has sufficient adipose covering over his ribs 
there cannot be a doubt about the advisability of putting one or two 
cupping glasses over the bites and extracting more blood. In thin 
patients this can be accomplished by hot fomentations. The action of 
the leeching may be intensified by the administration of a large saline 
purgative. The writer is by no means satisfied that leeching is of 
much use, and given a case where the extraction of blood is considered 
to be necessary by the urgency of the dyspnoea and other distress, he 
thinks that it will be safer to open a vein. 

Poulticing is the old-fashioned and still popular method of relieving 
the pain of acute pleuritis, and hot linseed cataplasms applied fre- 
quently afford the safest and least objectionable routine plan of treating 
mild cases of the disease where blood-letting and leeching are contra- 
indicated. The first poultice may contain half its weight of mustard, 
and the subsequent ones may be entirely of linseed meal, or the ingeni- 
ous plan mentioned on page 608 may be adopted. Poulticing may be 
advantageously stopped as soon as pain subsides. Cold applications, 
compresses, Leiter's tubes, or ice bags have been suggested and used 
instead of poulticing or hot fomentation. There is not sufficient evi- 
dence of the value of this innovation to justify one in recommending 
it as a routine practice, but enough proof of its occasional usefulness 



PLEURITIS, ACUTE. 665 

lias been demonstrated to warrant one in readily adopting it when 
warm or hot applications fail to afford relief. 

Blistering the chest for the relief of pain in the early stages of acute 
pleuritis has still many advocates. Fagge maintained that it appeared 
to him more serviceable thau any other measure ; it is often undoubtedly 
of much service during all the stages of the disease from its onset until 
the absorption of the last remnants of effused fluid. 

The blistering unfortunately interferes with the next remedial meas- 
ure for the relief of pain, though leeching and poulticing do not do so 
necessarily. 

Strapping of the affected side of the chest by means of stout strips 
of adhesive plaster, starting from the front of the chest on the sound 
side of the sternum, and ending upon the sound side beyond the spine, 
after enveloping the pained side firmly as in a vice, while the patient 
expires as forcibly as possible. This prevents the use of the affected 
lung and pleura to a great extent, and not only is pain relieved at once, 
but the rest is most beneficial as in the treatment of every other inflam- 
mation, and this method often appears to cut short the duration of the 
attack and the amount of effusion. A bandage three or four inches wide 
may also be used to relieve pain when applied tightly around the chest. 
This is known as Otto's method, and it is often valuable. 

The hypodermic injection of cocaine (J to 1 grain) over the seat of 
the pain has given relief. As a rule, in acute pleuritis, little satisfac- 
tion may be expected from anodyne liniments as belladonna, chloro- 
form, etc. 

During the time that these local remedies are being exhibited the 
morphine mixture, with the veratrum and antimonial wine, should be 
continued until the absence of pain and the subsidence of the fever 
call for its discontinuance. 

Up to this time the patient should be maintained in a position of 
absolute rest in bed, and this must be continued until the daily physi- 
cal exploration of the chest proves that the effusion has ceased to 
increase, or as long as the amount of fluid remains considerable. 

Diet is to be of the simplest, solid food being prohibited, milk and 
farinacious foods being the chief part of the diet. 

Purgative are not called for, except at the earliest and during the 
later stages, and alcoholic stimulants are seldom indicated until the 
disease passes into a chronic form. As the effusion increases there 
seems to be some chance that by diminishing the amount of liquid 
consumed the effusion may be held in check. If this is true it must 
only be to a very limited extent. 

For all practical purposes the question now becomes one of the treat- 
ment of the result of the pleuritis, or, in other words, of the treatment 
of effusion within the pleura. The first point for settlement is whether 
the case is one for surgical or medical treatment. If the effusion is 
moderate in amount, and does not by its quantity threaten seriously to 
embarrass the heart, and to impede respiration, there can be no doubt 

43 



666 PLEURITIS, ACUTE. 

that the physician is justified in waiting to see if absorption will com- 
mence. Remedies of considerable power in hastening this should now 
be tried. Locally and constitutionally the effusion may be attacked. 

Blistering is often very successful, and one large cantharidine plaster 
may be applied to the centre of the affected side of the thorax, where 
it may be permitted to remain for eight or ten hours, until thorough 
vesication results. As a rule, the plan of applying several small blis- 
ters for three or four hours each to different parts of the chest gives 
better results. These flying blisters may be made about three inches 
long and two and one-half inches broad, and may be placed upon dif- 
ferent parts of the chest wall at the same time. The- simplest way, 
however, is to use one blister, which should be kept on for, say, two 
hours near to the lower margin of the diaphragm. It may then be 
placed six inches higher up, and allowed to remain in contact with the 
skin for three or four hours, after which time it may be applied some- 
where near to the level of the upper limit of the effusion for six or 
eight hours. 

Sometimes the effect of this treatment is quite striking, and occasion- 
ally rapid diminution in the amount, of fluid may be dated from the 
time of trying the blisters. It is generally useless if tried while the 
amount of fluid is steadily increasing. 

Iodine tincture is a counter-irritant, or equal parts of tincture of 
iodine and glycerin painted on with the view of being absorbed, may 
be tried. Every known counter-irritant has been used, and occasion- 
ally with success. The iodine is, perhaps, the best of the class. 

Mercurial ointment (1 in 6 or 8) may be freely rubbed into the chest- 
wall, taking care that salivation does not follow from too long pro- 
tracted use of the remedy. If any improvement is to be got from its 
application, signs should show themselves during the first two or three 
days after its being used. The oleate of mercury may be used, or ex- 
cellent results may be obtained from applying a dilute mercurial oint- 
ment, or oleate of mercury ointment upon lint, and applying strapping 
over this, as by Roberts's plan. In this way the liniment of iodide oi 
potassium and soap (B. P.) may be used sometimes to great advan- 
tage. 

Internal remedies consist of absorbents like iodides, diuretics like 
caffeine and digitalis, purgatives of the saline class as sulphate of mag- 
nesia, and diaphoretics like large doses of jaborandi or pilocarpine. 

Some of these agents can be tried together. Thus, the following is 
a combination of value : 

R . — Tinct. digitalis . 3 iv. 

Tinct. scillae giij. 

Potassii iodidi ^ij. 

Decocti scoparii . . . . . ad ^ x. — M. 

S. — One tablespoonful to be taken in half a wineglassful of water after meals 
thrice daily. 



PLEURITIS, ACUTE. 667 

Pilocarpine, to be of use, must be given in such doses as will cause 
most profuse sweating ( J grain hypodermically), or one drachm of the 
fluid extract of pilocarpus. 

The first may now be changed to one in which the least possible 
amount of fluid is allowed, meat, biscuit, stale bread, or old cheese 
being only permitted for the first three days, a tumblerful of fluid being 
swallowed on the third day. Some authorities speak highly of a liberal 
diet of milk — five or six pints daily. All the above internal measures 
may be tried ; but, as a rule, they are uncertain and disappointing, 
and should not be too long administered. The best results are obtained 
from giving salines according to Hay's method (see 5th edition of the 
author's work on Materia Meclica and Therapeutics, page 451). After 
fasting, 1 ounce of sulphate of magnesia dissolved in the smallest quan- 
tity of hot water may be administered the first thing in the morning. 
Half this dose may be ordered twice a day for weak patients, and twice 
this amount may be given to strong plethoric ones. P. B. Smith 
records several cases successfully treated by smaller doses employed in 
this way, with a dry diet. 

Salicylate of sodium in full doses (30 grains), and salol (30 grains) 
four times daily are said to have a specific action over the effusion ; 
but the most glowing accounts of the remarkable effects of antipyrine 
in moderate doses (10 grains every four or six hours) have been re- 
cently published. The writer has not yet had an opportunity of testing 
the action of this drug over the effusion. Though he has used antipy- 
rine in the early stages of the affection for the relief of pain and fever, 
he had not noticed any specific effect upon the effusion. 

These measures, as already hinted at, are only warranted when the 
amount of fluid is not very extensive, nor are they to be used for any 
length of time, even when the amount of fluid is moderate, say 20 to 
40 ounces. Delay in the removal of the fluid means great risk to the 
lung, which is less likely to ultimately expand in proportion to the 
length of time during which it has been compressed by the fluid. 
Hence, when several weeks have elapsed with a moderate quantity of 
effusion in the pleura, though there be little inconvenience, and but 
slight displacement of organs, the fluid should be drawn off. Where 
the pleura is even filled only up to the angle of the scapula, and no 
symptoms whatever indicate to the patient that there is anything 
wrong, it is laid down that the fluid should be drawn off if it has 
resisted treatment for more than four weeks. 

If the patient be found to have the whole of the pleural cavity full 
when first seen, or to have both cavities half full, operation should not 
be delayed for the sake of trying the effects of drugs. Sudden death 
has been repeatedly noted when one cavity has been full, though no 
symptoms of pulmonary or cardiac distress were present to warn the 
physician of the impending catastrophe. Therefore, if in doubt, the 
best course is to decide upon immediate tapping. 

Various rules have been formulated for the guidance of the physician 



668 PLEURITIS, ACUTE. 

as to when operation or waiting is to be decided upon. Some authori- 
ties are influenced much by the symptoms of embarrassment of the 
breathing, others by the displacement of organs, others by the duration 
of the effusion, etc., but the error that generally underlies all these 
conclusions will be found to be that the simple operation of tapping 
is too often regarded as the last resource, only to be used when all 
others fail. 

The physician who decides upon purging, blistering, or diuretics in 
a case where dullness extends almost to the clavicle, will generally have 
his pains rewarded by the ultimate absorption of the effused fluid, but 
occasionally, though rarely, he may have the mortification of finding 
that his patient has been suddenly called to his long rest. More 
frequently will he experience that a tardy convalescence, with a par- 
tially collapsed lung and shrunken chest wall will remain as a monu- 
ment of his patience and faith in drugs. 

Procrastination often arises from some uncertainty in the diagnosis. 
This should never be. If the physician is in doubt, the ordinary 
hypodermic syringe and needle will easily give him the required con- 
fidence. Already the way that this .instrument may be utilized for 
exploratory purposes has been described. It should be thoroughly 
sterilized by immersion in some antiseptic liquid, and the cylinder 
being half filled with weak carbolic or corrosive sublimate solution, the 
instrument is held vertically while the piston is screwed home by a few 
turns, so as to fill the needle with the solution down to its extreme 
point. It is then plunged into an intercostal space deeply, and if the 
pleuritic fluid does not flow into the cylinder upon screwing out the 
piston, a few drops of the solution may be injected so as to clear the 
needle of any plug of fibrin or coagulated blood, after which the 
reversal of the screw will draw up a fair sample of the liquid out of 
the pleura. It may be a tax upon the credulity of the reader to be 
told that after withdrawing a dozen minims of the effusion such a 
change is sometimes set up in the pleura, and its contents as sometimes 
leads to a speedy absorption of the remainder, yet the writer has 
observed this many times in hospital practice when the puncture has 
been made as a demonstration of physical diagnosis in old long-stand- 
ing effusions. Such a result, however, is not to be counted upon where 
tapping is indicated in acute cases or where there is much liquid. 

The hypodermic needle may be inserted anywhere, but, as a rule, it 
will be best to introduce it at the spot where tapping is to be performed, 
as then the physician will be more confident in the introduction of his 
trochar and canula. If fluid is present he will so certainly find it that 
there is little fear of a negative result embarassing his future action, 
but cases have been reported where no fluid entered the syringe, 
though a larger instrument was successfully employed immediately 
afterward at the same spot. The writer is inclined to believe that this 
only occurs when an empty hypodermic syringe is employed. The 
spot to be selected for puncturing the pleura in paracentesis thoracis is 



ACUTE. 669 

not of very vital importance. Several situations have been recom- 
mended. The usual site is in tho axillary line in the fourth inter- 
space (i. e., above the margin of the fifth rib) upon the right side, and 
in the fifth space (i. e. above the margin of the sixth rib) upon the 
left side. Bowditch advises the puncture to be made between the 
ninth and eleventh ribs. It is advisable to keep close to the upper 
border of the rib in order to avoid the intercostal artery or to punc- 
ture fair in the centre of the intercostal space. Other authorities, 
while keeping to the fourth and fifth spaces, select a spot in front of 
the axillary line, while some puncture at a short distance in front of 
the posterior fold of the axilla. 

The most prominent or bulging space in any of these localities may 
be safely selected, and any spot should be avoided where there is 
reason to believe that the pleura is much thickened. 

The best form of instrument has already been discussed and described 
when detailing the treatment of empyema upon page 235, and there is 
no necessity for repeating the details here. 

Upon the whole the unequal suction force of the best aspirators is 
often a barrier to their usefulness in this operation and where the 
syphon principle is not considered satisfactory in any case* the writer 
employs Dieulafoy's aspirator, but after the fluid has commenced to 
run he does not exhaust the cylinder after emptying it each time, but 
slowly and patiently withdraws the piston and allows the fluid to flow 
in at a uniform and steady rate. The flow is too rapid when the 
piston is drawn up to the top of the cylinder and the stopcock turned 
fully on. 

In chronic cases with large effusions as in malignant disease of the 
pleura, the writer has inserted a Southey's trochar and canula, and 
after withdrawing the trochar, a fine rubber tube being attached to 
the canula, the fluid is allowed to flow into a basin under the patient's 
bed containing some carbolic lotion, the end of the rubber tube being 
kept under the surface of the liquid. 

Of course, the great object of the operator should be to evacuate 
the fluid without admitting air. The writer in one case found that 
air was admitted owing to the struggles of the patient — a very ner- 
vous child ; an excellent and rapid recovery ensued without a bad 
symptom. 

It is generally not advisable to remove all the fluid in the pleura, 
but the writer finds that the slowly flowing capillary stream from a 
Southey's canula may be safely permitted to run until the cavity empties 
itself. It is different with the quickly acting aspirator, and as a rule, 
the quicker the flow the greater is the danger of syncope, coughing, 
or dyspnoea. Should such symptoms supervene the suction must be 
discontinued for a time without withdrawing the needle or canula, 
and as soon as marked embarrassment supervenes, the operator had 
better withdraw, the canula and trust to nature for the absorption of 
the remaining fluid which always happens. 



670 PLEUKITIS, ACUTE. 

After withdrawing the canula, a small pad of lint, soaked in any 
antiseptic liquid, may be quickly placed upon the site of puncture, 
where it can be fastened by a few strips of adhesive plaster. Cough- 
ing, if it continues, may be relieved by a hypodermic injection of 
morphine, or by tightly bandaging the chest with a deep or broad 
binder. 

After the operation is concluded the organs, which had been dis- 
placed, may be found partially restoree to their normal position, and 
day by day the physical signs become nearer to the normal. Some- 
times a second or a third tapping may be required. Should pus be 
found at the first time of withdrawing the fluid, or at any subsequent 
time, the treatment described under empyema on page 235 will then 
be considered advisable. The utmost care must be taken to prevent 
an ordinary pleural effusion from being converted into a purulent one. 
This may be caused by the use of soiled instruments or by the admis- 
sion of air during the tapping. 

Sometimes a thickened pleura or a large deposit of lymph may give 
rise to difficulties in getting out the fluid. The latter may be pushed 
in front of the trochar or canula, but the experienced operator after he 
has punctured the skin by the instrument takes a short grip of the 
latter as he causes it to penetrate the remaining tissues with a sudden 
push or jerk, which is certain to penetrate instead of pushing the mem- 
brane before it. 

When the canula gets blocked there is some danger in attempting 
to clear it, The writer has driven out plugs of fibrin by forcing back 
some of the fluid out of the aspirator cylinder, but this should not be 
attempted unless the instrument has previously been rendered aseptic 
both inside and out, and only when the fittings are absolutely air-tight. 

The canula with stop-cock, mentioned under Empyema, admits of 
being easily cleared of obstructions by pushing back the trochar with- 
out the possibility of air being admitted at the same time, and this is a 
great advantage. 

Where localized or circumscribed collections of pus are found each 
cavity may require to be separately punctured and tapped. 

Professor Lewsaschew has introduced a method of treating pleuritic 
effusion which appears to be a distinct advance, and it can be used 
also in purulent cases. Its object is to do away with the untoward 
results which sometimes occur from the disturbance of the balance of 
intra-thoracic pressure. He withdraws a small amount of the fluid 
until some uneasiness is felt by the patient, and then he injects, by a 
reversed action of the aspirator or syphon, an equal amount of a steril- 
ized solution of chloride of sodium (0.7 per cent, in distilled water.) 
After the balance is thus restored he continues the aspiration for a 
time, and again reverses the action injecting in more saline solution 
until little but pure solution is left behind. Where no adhesions exist 
this method gives excellent results in pleurisy and empyema. 

The diet after tapping should be of the most sustaining nature, and 



PLEURODYNIA, 671 

every remedial agent calculated to improve the general nutrition should 
be giveu, as tonics with iron, quinine, and cod-liver oil, change of 
scene, etc. Where a tendency to re-accumulation occurs, and when 
the residual fluid after partial emptying of the pleura appears slow in 
disappearing, the treatment already mentioned must be persisted in, as 
blistering or counter-irritation, iodides, and diuretics, with saline pur- 
gatives like Friedrichshall, Carlsbad salts, or Hunyadi Janos water. 
Chronic dry pleurisy is best relieved by blisters or strapping, 

PLEURODYNIA. 

The treatment of this affection will consist in the exhibition of the 
remedies suitable for muscular rheumatism. In acute cases one or two 
full doses of salicylate of sodium (30 grains) given after a hot pack, or 
a Turkish or hot air bath often act very speedily. 

After making an impression upon the pain in this way, the effect 
may be kept up by smaller doses or by 8 or 10 grain doses of antipy- 
rine every six or eight hours. Salol, in doses of 15 to 20 grains, is a 
most trustworthy remedy. After the acute symptoms have subsided, 
or in chronic cases from the first, alkalies in full doses, in conjunction 
with the iodide of sodium or of potassium should be given.* 

Be. — Sodii iodidi gij. 

Potassii bicarb. . ^j. 

Tinct. cimicifugae 5yj. 

Aquae camph ad ^xij. — M. 

S. — A tablespoonful to be taken three times a day after meals. 

Quinine, though highly recommended, has seldom been of any use 
in the writer's hands, but in very chronic cases arsenic is valuable 
when given in combination with iron in anaemic subjects. 

Local treatment is of greatest service. If the pain is unbearable the 
speediest remedy will be a hypodermic injection of morphine (-J- grain) 
given directly over the pained region, and if the patient must move 
about his business the chest should be strapped by Otto's method so as 
to entirely restrain the movements of the affected side. This generally 
affords instant relief if properly done. Belladonna and opium plaster 
may be used for the strapping. Any of the various auodyne liniments 
may be useful. Thus a piece of lint saturated in a mixture of equal 
parts of tincture of aconite and of liniments of belladonna and chloro- 
form, may be laid upon the part and covered over with oiled silk and 
a bandage. Menthol, or chloral and camphor, may be rubbed over 
the part. 

Cupping, blistering, or smart counter-irritation with iodine, mustard, 
croton oil, Chilli paste, or tartar emetic ointment, may be used. The 
continuous current or static electricity is often very useful. In severe 
cases acupuncture after freezing with the ether sprav may be tried. 



672 PLUMBISM. 

PLEURO-PNETJMONIA— See under Pneumonia. 
PLUMBISM. 

The treatment of acute poisoning by the salts of lead will be stated 
under the head of Poisons. In chronic lead poisoning the patient 
should be persuaded to give up his occupation for a time, if it be clear 
that the lead got into his system in this way. Minute examination of 
the patient and his surroundings should be made to determine the 
source of contamination, and this should, of course, be stopped at once. 
The symptoms may require immediate relief. Thus the violent pain 
of lead colic must be relieved by a hypodermic injection of morphine, 
but no permanent relief can be counted upon until free purgation is 
established. Two drugs give excellent results — sulphate of magnesia 
and castor oil. When very obstinate constipation exists, 1 ounce of 
castor oil, in combination with J minim of croton oil, may be given. 
For prolonged use the sulphate of magnesia, in small morning doses, 
is to be preferred. 

. Iodide of potassium is of the greatest value. It forms a soluble salt 
with the lead in the system, and this appears after a time in the urine. 
It may be given in any form, and often acts best when combined with 
the saline purgative just mentioned. Five grains of the iodide may 
be given three times a day after meals, and 1 drachm of the sulphate of 
magnesia, three times daily, before meals. 

Alum is also of use, and, combined with opium, it often is found to 
purge gently in painter's colic. 

Sulphur baths, or baths of the soluble sulphides or sulphurets, are 
recommended, but there is room for doubting their usefulness. Sul- 
phur internally is beneficial. 

The rectal injection of the vapor of ether has been found useful in 
the treatment of lead colic. 

For the elimination of the poison, Semmola has recently obtained 
excellent results, and these have also been corroborated by other ex- 
perimenters. He placed the patient in an acidulated bath, and laid 
one pole of the continuous current upon the tongue, while the other 
pole was dropped into the water. Though no lead was found upon 
the sides of the bath or in the water, the urine was found some days 
afterward to show that increased elimination was taking place. The 
bath was then dispensed with in other cases, and one pole was placed 
upon the tonge, and the other upon the pit of the stomach, or one pole 
over the vertebral column, and the other over the stomach. In all 
cases the urine showed increased amounts of lead, and the blue line 
disappeared in about three weeks, except in those cases where satur- 
nine encephalic symptoms were present. 

Electricity is the remedy for local paralytic lesions, and it may be 
used with advantage even when no paralysis is observable, but where 
the reaction of degeneration is present. The continuous current may 
be applied to the affected muscles and to the nerves supplying them. 



PNEUMONIA. 673 

The induced current may be also occasionally used. This treatment 
should be patiently persisted in for long periods. Massage may be 
tried in conjunction with it, and the results just mentioned as obtained 
by Semmola suggest that the beneficial effects of the current may be 
possibly owing to the increased elimination. Erb has suggested gal- 
vanization of the spinal cord, which probably would be beneficial in 
the same way. (See also under Colic, on page 132, and under Paralyses, 
on page 578.) 

The prophylactic treatment of all persons subjected to the action of 
lead is of the utmost importance. The most rigid attention to personal 
cleanliness is essential. Painters who never eat in their paint shops, 
and who always carefully wash their hands before meal times, escape, 
while their less scrupulously clean companions suffer. Where the dry 
dust of any lead compounds saturate the air of workrooms or manu- 
factories, the workers should be educated to keep their mouths closed, 
and do all the breathing through the nose, or respirators should be 
worn, and the freest possible ventilation be insisted upon. 

Lemonade mad-e in the ordinary way, but containing free sulphuric 
instead of citric or tartaric acid, has been found useful, or the acid may 
be administered in conjunction with a morning dose of sulphate of 
magnesia in very dilute solution. 

PNEUMONIA. 

There is much that is most unsatisfactory in the present aspect of 
the treatment of pneumonia. Mild cases of the disease do well with 
almost any treatment, but there are grave differences of opinion re- 
garding the best methods of dealing with the worse forms of the dis- 
ease. 

The writer believes that what is at present called pneumonia is but 
a local or secondary manifestation of several totally distinct constitu- 
tional affections which we are not yet able to differentiate. The first 
satisfactory progress in the treatment of pneumonia will begin after 
the natures of these separate affections have been demonstrated. For 
the present the physician must be content to treat pneumonia upon 
the same rational lines as are indicated in the management of the con- 
tinued fevers, with such modifications as the extent, nature, and 
severity of the local pulmonary lesion will suggest, taking care to steer 
his way clearly between the warm bed and peppermint water treat- 
ment, and the heroic calomel, blood-letting, or alcoholic plans. 

In the very early stage the patient is, of course, to be put to bed, to 
have a moderate amount of clothing, and an abundance of fresh, pure 
air of an equable temperature— say about 60° F.— and a milk diet. 

The popular idea of the danger of draughts should compel the phy- 
sician to superintend the ventilation and heating of the sick room. 
The writer would urge that a few screens, covered with light muslin, 
and about six feet in height, should be placed at a little distance 
around the patient's bed, which must not be in a corner of a room. 



674 PNEUMONIA. 

With such a contrivance as this, doors, windows, and ventilators may 
be safely left freely open, even in moderately cold weather. 

The most that should be attempted in the way of drugs should be 
the administration of a mild saline cathartic alone or preceded by 3 
grains of calomel. When the bowels have been thus cleared out, the 
hot skin may be made to act, the cough may be soothed, and the pain 
in the chest relieved by a simple combination like the following : 

B . — Morphinse hydrochlor gr. J. 

Liq. ammon. acetat . . . . . . ^ij. 

Vini antimonii . Tit lv. 

Aquse camph q. s. ad ^viij. — M. 

S. — One tablespoonful to be taken every four hours. 

With the administration of the above, large, hot, linseed poultices may 
be applied every three or four hours. It is best to redden the skin 
well at the start by mustard, and to keep up the effect afterward by 
plain linseed, or the plan of combining a pure mustard and simple 
linseed poultice, as mentioned upon page 608, may be adopted. The 
poultices should be spread upon flannel, and should extend from the 
spine to the sternum of the affected side. 

Where these simple measures fail to relieve the pain in the chest, a 
a larger dose of morphine may be given hypodermically, but though 
this pain is probably owing to some pleuritis which it constantly present 
in pneumonia, the same freedom in the use of anodynes is not admis- 
sible, owing to the danger of interfering with the expectoration and its 
evacuation. With care, however, pain at this stage can generally be 
kept in check or almost entirely relieved by opiates. 

Hot fomentations (to which any of the innumerable anodyne lini- 
ments can be added), cupping, blistering, and leeching may be con- 
sidered necessary. A method used by Goodhart and Fieandt with 
marked success consists in applying continuously a large rubber ice- 
bag over the affected lung. After several hours of this application, 
pain may disappear, cough may lessen, and very often a marked fall 
in the fever heat takes place, so much so that many Continental physi- 
cians use the ice-bag as an antipyretic. Cold compresses may be tried 
as a sort of compromise between this treatment and that by hot poul- 
ticing or fomentations. 

Formerly blood-letting was freely practised for the relief of pain 
and with the view of cutting short the disease. There cannot be a 
doubt that as a routine method this raised the death-rate, and it is 
very probable that many patients died from the heroic blood-letting 
who would have lived had nothing whatever been done for them. 
Nevertheless, it is just as likely that some few patients nowadays 
are permitted to die for want of blood-letting. With a firm, incom- 
pressible pulse in a strong plethoric subject who is suffering from 
dyspnoea, or much pulmonary embarrassment . and lividity, blood- 



PNEUMONIA. 675 

letting may still be relied upon to turn the scale in the patient's 
favor. 

Leeching will not accomplish this. This slow method of removing 
a small amount of blood will not produce any marked benefit in 
severe cases, though it may relieve local pain, but in conjunction with 
a smart saline purge and the application of one or more cupping glasses 
over the leech-bites a good effect has been several times obtained by 
the writer. 

Some authorities maintain that at this early stage of the disease it 
may be rendered abortive by large doses of quinine (30 grains), calomel 
(10 grains), by very cold baths, and other measures. This is so unlikely, 
and at constant variance with experience, that when abortion does take 
place most observers will conclude that it was either a mistake in diag- 
nosis or a natural freak of the disease. 

The temperature should be watched closely, and when, say 104 
or more degrees are recorded, it will be wise to consider what is to 
be done to reduce it. Various measures are feasible. The writer 
prefers antipyrine in moderate doses — say 10 grains every four or six 
hours. This is comparatively safe, and, when used with discrimination 
and the effects watched, it is perfectly safe, but the results are not con- 
stant. 

Other new antipyretics, as antifebrin, salol, and exalgine, may be 
tried, but of the latter enough is not known to warrant a definite or 
strong opinion. 

Quinine is a favorite drug with many eminent authorities, but the 
writer has seen it do harm when given in doses sufficient to produce a 
marked impression upon the temperature. It is sometimes given to 
the extent of 20 or 30 grains at Once. This amount may dry up the 
expectoration and embarrass the patient's breathing by greatly increas- 
ing the cough trouble, and, moreover, it may fail altogether in re- 
ducing the temperature. 

Salicylate of sodium, though open to many objections, if pure, answers 
even better than quinine (salicin is safer than the soda salt), but both 
are, perhaps, inferior to antipyrine. 

The ice-bag applied to the chest, as already mentioned, is sometimes 
effectual, and it relieves pain at the same time, but it may aggravate 
pain in some cases. 

Fenwick has introduced an excellent plan for the abstraction of 
body heat by a constant current of cool air. He has demonstrated its 
great value in pneumonia. It consists of a large and wide iron sur- 
gical cradle, from the central bar of which are suspended several 
small zinc pails half filled with ice. The patient, covered with a 
light sheet of opaque gauze, lies undressed upon the bed, and the cradle, 
covered by a light counterpane, is placed over him ; a hot water bottle 
is placed at his feet. This plan may be kept in operation for many 
days, and when hyperpyrexia threatens, cold sponging may be tried in 
addition. 



676 PNEUMONIA. 

Cold baths are greatly used on the Continent in the treatment of 
pneumonia, and some authorities use them as a routine method even 
when the temperature does not exceed 102° or 103° F., and claim a 
low mortality. A bath of the temperature of about 60° is employed, 
and the patient is immersed for fifteen to twenty-five minutes, the pulse 
and temperature being closely watched. In mild cases, one must con- 
clude that they are often unnecessary, and the difficulty of lifting a 
weak patient into and out of a bath is not one to be lightly undertaken 
in a disease in which the main principle of treatment should be to 
husband or save up any scrap of strength which the patient possesses. 
In such cases it has always appeared to the writer more rational to 
resort to cold sponging or wet compresses. It does not do away with 
this objection to quote a low mortality where the cold bath is used in 
a routine way, for the mortality might be still further reduced if the 
use of the bath was confined to selected cases. In hyperpyrexia with 
a fever heat of 105° or more, the cold bath is the best agent which we 
possess, and undoubtedly it affords the patient the best chance for life. 
Under such conditions all other antipyretics should be abandoned as 
waste of time in dealing with pneumonia. 

The patient may be kept in the bath until the temperature falls to 
about 100°, and the heat of the bath may be reduced to 40° in severe 
cases. As the fall continues after his removal to bed, it is seldom wise 
to wait until the fever heat falls entirely to the normal during the 
immersion. Where there is much prostration the heat of the bath 
may be gradually reduced from about 80° F. at the beginning of the 
immersion to 50° F. at the end by adding cold water or ice. A full 
dose of stimulant may be given before the patient leaves his bed, and 
this may be repeated while in the bath or after he has been laid in bed 
again. The effect upon the pulse, temperature, and general condition 
is to be the guide when the question of repeating this treatment crops 
up again in four, six, or eight hours after the bath. 

As failure of the heart's action is one of the most frequent causes of 
death in pneumonia, the pulse should be watched from the very onset 
of the attack, and as soon as the least sign of cardiac failure is notice- 
able the free exhibition of alcoholic stimulants is indicated. 

It is not advisable, however, to order alcohol in a routine fashion in 
all cases of pneumonia from the beginning. In the early stages it may 
do harm. When the pulse shows signs of weakness and frequency the 
stimulant should not be withheld. Such is the present doctrine, and, 
although generally received and acted upon, there are not wanting 
signs which point to a serious modification of professional opinion in 
this direction. Nevertheless, with a pulse of 120, and compressible, 
one is not justified in withholding a large amount of alcoholic stimu- 
ulants, considering our present knowledge of the disease; 8 to 12 
ounces, or even 20 ounces, of good whiskey (of at least five years old) 
may be given in very severe or desperate cases. It is better to give 



PNEUMONIA. 677 

the whiskey in milk — a tablespoouful may be given in a large wine- 
glassful of milk every hour or every two hours. 

The writer believes that one serious mistake is often made in such 
cases — the patient being able only to take a small amount of nourish- 
ment, the physician or nurse insisting upon the alcohol, it may then 
become almost the only thing the patient takes. 

Food is of vital importance from the beginning, and if more attention 
was bestowed upon it there would often be less necessity for thinking 
of alcohol. Beginning with milk, beef tea and strong soups or beef 
essences should be liberally administered, and the effect of large quan- 
tities of a carefully-prepared beef tea upon the failing cardiac muscle 
is not to be lost sight of. Though such a dietary can hardly be ex- 
pected to build up tissue in a state like that in which the pneumonic 
patient is in, it certainly will tend to prevent tissue waste, and may 
save the patient's life by saving his cardiac muscle. The danger of 
over-stimulating the heart must not be lost sight of. Brandy may be 
given instead of whiskey ; but, as a rule, wine in any form is inferior 
to these. 

Digitalis has been strongly recommended in the treatment of 
pneumonia, both as a cardiac tonic and antipyretic. Petresco states 
that he has used this drug in large doses for the past six or seven 
years in every case of pneumonia " with eminently satisfactory results, 
the attack usually aborting by the second or third day, sometimes the 
patient being able to return to work after twenty- four hours." 

The writer gave the drug a fair trial some years ago, and resolved 
never to depend upon it again, as it invariably proved a failure when 
used by itself. In no instance has he observed any marked antipyretic 
effects from it in pneumonia. Where cardiac power is failing, in spite 
of the free exhibition of alcohol, and where the breathing and cough 
are troublesome, the following combination may be tried : 



R. — Spt. ammon. aromat, 
Spt. aether. 
Tinct. digitalis 
Moschi . 
Vin. ipecacuanha? . 
Tinct. cinchona? 



3* 



3j- 

gr. lx. 
ad ^vj. — M. 



S. — One tablespoonful to be taken every four hours in a wineglassful of water. 

This is a powerful diffusible stimulant, and, though the amount of 
digitalis in it is very much less than is recommended by those who 
use the drug as a specific for pneumonia, still it will be well to watch 
its effects upon the urine, and to omit this ingredient of the recipe if 
there should be anything like suppression after the above has been 
administered for three or four days. Petresco gives as much as 60 to 
160 grains of the leaf daily in infusion. 

Caffeine or the very soluble double salt — the sodio-salicylate — is 



678 PNEUMONIA. 

safer than digitalis, and acts more rapidly in cases of cardiac failure. 
One grain may be given every three hours in conjunction with stimu- 
lants. Spartein may be pushed with safety. 

Under conditions like those just mentioned, blood-letting is still ad- 
vised by some, but the benefits to be expected from it get less and less 
as the disease advances, and at this stage it would appear to be unjus- 
tifiable, unless in the presence of great dyspnoea and lividity, with a 
full pulse. 

For cardiac failure in pneumonia there is, perhaps, no drug to be 
compared with strychnine in full doses, and the writer does not 
hesitate to recommend it in full hypodermic doses under these cir- 
cumstances. 

Sleeplessness will require careful management, and before the in- 
troduction of the valuable hypnotics of recent years, there was 
nothing before the physician but the ice-cap and opium or mor- 
phine. As already stated, there is much risk in giving narcotics on 
account of the nature of the expectoration. Choral is decidedly 
objectionable. In the opinion of the writer, its use in pneumonia 
is unwarrantable, owing to the danger of its cardiac depressant 
action. 

Sulphonal, given in a little whiskey punch, is the best of all 
hypnotics in a condition like that of a serious pneumonic attack. 
Thirty grains may be given. 

Paraldehyde is also safe and efficacious. The cold bath often 
relieves the delirium, insomnia, and dyspnoea when these symptoms 
are dependent upon or associated with a high temperature, if asthenia 
is not well marked. 

The above measures may be expected to save life in those severe 
and desperate cases which probably would succumb to a purely 
" expectant " treatment, though there is no doubt mild cases, and 
sometimes every case in a mild epidemic, may be successfully treated 
by the expectant method. 

Other plans of treating pneumonia are being extensively tried, and 
most encouraging reports are published of the results, but as the 
writer has no personal experience of their use, he need only briefly 
refer to them. 

Clemens has been treating pneumonia by inhalations of chloroform 
during the last forty years, with only two deaths at the beginning of 
this period. He mixes the chloroform with alcohol, and saturates a 
piece of firmly twisted lint with the mixture. This is wrapped up in 
dry cotton, and held near to the patient's mouth and nose, so as to 
permit of the vapor being freely mixed with air. Narcosis is not to 
be produced. He claims for this treatment that it defibrinates the 
blood and modifies the local process of inflammation, so as to gener- 
ally prevent hepatization, and that it hastens the termination and 
leads to the rapid disappearance of the physical signs of the 
disease. 



PNEUMOTHORAX. 679 

Inhalations of oxygen have been highly recommended, and per- 
oxide of hydrogen internally has been used extensively by Green in 
30 minim doses, largely diluted every hour. 

Numerous observers report glowingly of calomel, and Strong re- 
ports twenty cases treated successfully by doses of 20 grains every 
three hours, with no ptyalism and little catharsis. 

Iodide of potassium has been successfully given in doses of 15 grains 
every three hours during the day and night by Nilsson. 

Aconite, veratrum viride, arnica, gelsemium, muscarin, pilocarpine, 
acetate of lead, and many other drugs have been vaunted, but as the 
majority of these in even moderate doses depress the action of the 
heart, they need only be named to be condemned. 

Sturges and Copeland, whose authority in this question is entitled to 
the greatest respect, state that there are no drugs possessing a specific 
action in pneumonia, and that the treatment of symptoms as the 
hyperpyrexia, pain, insomnia, etc., are the points calling for attention. 
They regard active delirium and asthenia as indications for free stimu- 
lation, and dyspnoea for bleeding from the arm. Believing that the 
more active treatments have given a higher mortality, they state that 
they are content with the adoption of means which have the advan- 
tage of obvious reasonableness, resting not on the shifting sand of to- 
day's therapeutics, but on broad principles of conduct universally 
recognized and understood. With this the writer fully agrees, and 
thinks their remarks a fair commentary upon the list of active drugs 
just mentioned. 

During the later stages of pneumonia, after the temperature falls, 
and the immediate danger seems to have passed, the greatest care 
should be exercised, as the heart may still require assistance. 
Stimulants should be continued for a little time in full and then 
in gradually diminishing amounts, but all antipyretic or depressing 
remedies must be carefully avoided and the horizontal position 
maintained during convalescence. The most liberal diet is to be 
kept up, and the following tonic, or anything possessing similar 
action, may be safely administered. Fellow's and Easton's syrups 
are valuable. 

R. — Strychninse . . . . . . . . gr. f . 

Acid, nitrohydroclor. dil. 3 v. 

Quininse sulphatis gss. 

Infusi calumbae ad ^viij. — M. 

S. — A tablespoonful in a little water before meals three times a day. 

PNEUMOTHORAX. 

The treatment of air and pus in the pleural cavity has been men- 
tioned under Empyema, upon page t 235. In those cases where air has 
suddenly found its way into the cavity by perforation or rupture of 
the visceral pleura without external injury, recovery often follows if 



680 POISONING. 

the patient is kept quiet. Where pain is distressing, small inhalations 
of chloroform, cupping, venesection, or hypodermic injections of mor- 
phine, may be tried. 

Where there is evidence of the air within the thorax being at a higher 
pressure than the outside atmosphere, as proved by the great distension 
of the side and marked displacement of organs, tapping by a fine trochar 
and canula is necessary. It is generally held that this should not be 
done until a sufficient time has expired in order to allow of the closure 
of the aperture in the visceral pleura through which the air originally 
passed outward. Albersheim has, however, shown that frequent aspi- 
rations do not prevent closure of the aperture, and they effectually pre- 
vent the formation of such adhesions as are fatal to the future through 
expansion of the lungs. Hence he advises aspiration. 

The best rule for guidance should be that no operative interference 
is to be undertaken, except in the presence of very marked pain and 
distress, and then it will generally be found sufficient to tap with a fine 
trochar, so as to permit the free escape of the imprisoned air, until 
equilibrium is established. A drainage-tube may be left in where there 
is much fluid or fetor, but as a rule, when this is the case, the larger 
opening desirable in doing the ordinary empyema operation should be 
made. Bouverst recommends the internal use of opium to stop all 
coughing, and he insists that the canula should be left in situ. 

POISONED WOUNDS— See under Wounds and Septicsemia. 

POISONING. 

In the treatment of poisoning, the first consideration in the great 
majority of cases will be to evacuate the contents of the stomach when 
this is possible. This may be accomplished by emetics or by the stom- 
ach-pump, or by tickling the fauces when these agents are not at hand. 
In poisoning by the strong mineral acids and all corrosive substances 
the stomach-pump is contra-indicated, but in the case of corrosive sub- 
stances like carbolic acid this may be used cautiously if a soft tube be 
employed. Indeed, the soft India-rubber tube of the stomach-pump 
can scarcely do any harm except in the most destructive instances of 
poisoniug by concentrated sulphuric or nitric acid, and the pump should 
always be fitted with such a tube in at least two sizes. When at hand, 
the pump should be preferred to every other means of emptying the 
stomach, and except in the limited number of cases just mentioned, it 
may be used even when there is room for considerable doubt in the 
diagnosis of poisoning in patients found in insensible or comatose con- 
ditions. The coroner's court will justly censure the practitioner who 
has been in attendance upon a patient picked up in an insensible con- 
dition if the evidence afterward produced proves that a narcotic poison 
had been swallowed, though when seen by the physician no such evidence 
had been forthcoming and the symptoms pointed to head injury, uraemia, 
or apoplexy. The cautious use of the pump with the rubber-tube, 



POISONING. 6S1 

when scientifically carried out, can in no way injure the patient's 
chances of recovery should the case ultimately turn out not to be one 
of poisoning ; and as every minute's delay may be serious for the pa- 
tient, and as there is thus short time for counsel and debate, he should 
be prepared to act accordingly and make his error upon the safe side. 

The first time of using the stomach-pump is sure to be a bungling 
affair if the operator feels timorous or nervous. The tongue being 
depressed by the left index-finger as the patient is seated in a chair, 
with the head well steadied by an assistant, and the gag in position, the 
tube is to be pushed steadily, boldly, and rapidly through the mouth, 
pharynx, and oesophagus until the stomach is reached. Though it is 
more difficult to pass the soft rubber tube, the confidence in its perfect 
harmlessness will be of great importance to the novice. He should 
not be deterred by the sound which may be produced by air passing 
through the tube as its extremity glides past the epiglottis, this ceases 
as the rubber is passed home into the stomach. During the pumping, 
by reversing the action of the levers, a little water may from time to 
time be sent into the stomach to clear the tube of any solid obstruction, 
and before withdrawing it finally, tepid water should be injected into 
the organ, and this should be pumped out again, the operation being 
continued until the washings return clear. The antidote may be mixed 
with the water, and in many instances a quantity of this should be left 
in the stomach. In pumping opium or alcohol cases, after the washings 
return clear and free from odor, the stomach may be partially filled 
with strong infusion of tea or coffee. 

The syphon tube may take the place of the stomach-pump in most 
cases. 

Thirty grains of sulphate of zinc or 10 grains of sulphate of copper 
in a tumblerful of tepid water will prove efficient emetics ; and apo- 
morphine, y^ grain injected hypodermically, acts with great certainty 
and rapidity when the patient is unable to swallow. Notice should be 
taken of the fact that though patients may often take apomorphine in 
doses of 4 to J grain by the mouth without experiencing nausea, this 
dose might prove fatal if given by the hypodermic method, owing to its 
rapid depressant effect upon the heart. 

Mustard in dessertspoonful doses, in copious quantities of tepid 
water, may be used when the above emetics are not at hand. Ipecac- 
uanha and antimony are too slow in their action to be depended upon. 

The contents of the stomach when ejected (or when obtained after- 
ward upon opening the body) should be carefully preserved for further 
investigation. This is often overlooked in the exciting period of 
treatment. 

The writer has several times successfully pumped and washed out 
the stomachs of infants and very young children with a soft India- 
rubber male catheter, attached to the nozzle of an ordinary large glass 
or metal syringe. 

44 



682 POISONING. 

The following formula (from the Pharm. Rundschau) may be em- 
ployed as a general antidote for any poison of unknown nature : 

R . — Calcined magnesia ^ 

Powdered wood charcoal >■ . . Equal quantities. — M. 
Hydrous peroxide of iron J 

Half an ounce of each of these may be given in a tumblerful of 
water every half hour until three doses be taken. 

The following brief alphabetical list of poisons, and their antidotes 
and treatment is taken from the 5th edition of the author's work on 
Pharmacy, Materia Medica, and Therapeutics" page 623, and may prove 
useful for reference in emergency : 

Acids, Mineral. 

The stomach-pump should not be used. Alkalies — lime, soap, chalk, 
potash, soda, or magnesia — moderately diluted with water, may be 
freely given. In the absense of these, plaster off a wall, oils (almond 
or olive), and small doses of morphine hypodermically should be 
administered ; all food should be given by the rectum. At a later 
stage, when the danger of perforation has passed off, bland mucilagi- 
nous foods, like barley water, linseed tea, and white of eggs may be 
freely given. 

Acid, Prussic (or Hydrocyanic). 

The stomach, if possible, should be emptied by the stomach-pump or 
by a rapid emetic (i drachm of sulphate of zinc) ; hypodermic injec- 
tions of atropine (-^j grain) ; 2 minims of the 1 : 100 solution of atro- 
pine may be given, and repeated in thirty minutes if necessary. 
Ammonia, or whiskey, inhalation of oxygen, ammonia, or chlorine, 
cold and hot affusions alternately, and artificial respiration, are the best 
agents to resort to. 

Freshly precipitated oxide of iron, followed by a solution of car- 
bonate of potassium, is to some extent a chemical antidote, but free 
stimulation after the evacuation of the stomach must be alone relied 
upon. 

Aconite (and Hellebore or Veratrine). 

The stomach-pump or emetics should be used ; -^ grain of apomor- 
phine hypodermically, or a tablespoonful of mustard in warm water, 
or J to 1 drachm of sulphate of zinc should be given as soon as possi- 
ble. Stimulants — whiskey and ammonia hypodermically, with 20 to 
30 minims of tincture of digitalis or 2 minims of liquor atropine 
(1 : 100) should be then administered. Strychnine may be given 
(-^q grain) by mouth, rectum, or hypodermically. 

The patient should be kept horizontally on his back, and in a state 



POISONING. 683 

of absolute rest, and sinapisms applied to the heart and extremities ; 
and dry heat, friction, and artificial respiration kept up unceasingly. 
Murrel recommends inhalations of nitrite of amyl. 

Alcohol. 

The stomach-pump should be promptly used, and the stomach filled 
through it with strong coffee, to which a little ammonia should be 
added ; or a hypodermic injection of T V grain of apomorphine may be 
given in the absence of the pump; sinapisms, cold affusion, nitrite of 
amyl inhalation, or electricity may be tried, and in desperate cases, 
boiling water may be used to cause immediate vesication of the skin 
over the soles of the feet. The hypodermic injection of T \-$ to -^ 
grain of strychnine is of unquestionable value, as pointed out by 
Gibson. 

Ammonia and Alkalies. 

The stomach-pump should not be used. Weak acids (acetic prefer- 
able) may be given, largely diluted, and followed by draughts of 
almond or olive oil or of melted butter, and demulcent drinks. 

Tracheotomy may be required for the oedema of the glottis, and 
morphine hypodermically for the shock. 

Antimony (Tartar Emetic). 

Stomach-pump or emetics are not generally required, as vomiting 
sets in soon. Tannin, strong tea, or gallic acid, or any diluted astrin- 
gent tincture or infusion containing tannin, may be freely given, fol- 
lowed up by the hypodermic or rectal administration of alcohol, to 
which small doses of digitalis or strychnine may be added. White of 
egg, barley water, or linseed tea may be given freely. 

Butter of Antimony. The treatment of poisoning by this prepara- 
tion of antimony should be the same as for the mineral acids — viz., 
magnesia, soap suds, chalk, potash, or soda, followed by oil and milk. 

Arsenic. 

The stomach-pump or emetics, or ^ grain of apomorphine should be 
injected even when vomiting has already taken place. Freshly pre- 
pared moist peroxide of iron (prepared by adding soda or ammonia to 
the tincture of iron, and filtering rapidly through muslin or cambric) 
or dialyzed iron in ounce doses, diluted, or, in the absence of these, 
magnesia freely, or animal charcoal, olive oil, or lime-water, must be 
freely given ; demulcent drinks and stimulants by mouth or rectum are 
also indicated. Large doses of castor oil are essential to clear out the 
intestinal tract and to prevent further absorption. 



684 POISONING. 

Atropine and Belladonna. 

The stomach-pump or emetics, and afterward the following are to be 
given : Tannin, charcoal, or tea, morphine (i grain) by subcutaneous 
injection, or laudanum by the mouth, or pilocarpine (i grain) subcu- 
taneously, followed by purgatives. 

The poison being excreted by the kidneys, the bladder should be 
emptied by the catheter to prevent reabsorption. Eserine in small 
doses has been advocated as an antagonist, but pilocarpine is better. 
Free stimulation, counter-irritation, and artificial respiration may be 
necessary. 

Cannabis Indica. 

The stomach-pump or emetics, especially apomorphine hypodermi- 
cally (-^j- to -§- grain), are to be given, and the symptoms treated as 
they present themselves. It will generally be found necessary to both 
purge and stimulate. 

Camphor. 

Stomach-pump or emetics, and copious draughts of water, with brisk 
saline cathartics, and general counter-irritation, or cold and hot douches 
alternately, afford the best means of dealing with this poison. 

Cantharides. 

Stomach-pump or emetics, mucilaginous drinks, or, in their absence, 
oils, chalk, a little opium by the mouth, and a morphine suppository 
by the rectum, should be used. 

Carbolic Acid. 

The stomach-pump with its soft rubber tube should be used, after 
which the organ should be thoroughly washed out with pure glycerin 
or with solution of Epsom or Glauber's salt. Give oils, egg albumin, 
and warm mucilaginous drinks, with any soluble sulphate, and finally, 
freely stimulate, counter- irritate, and inject ^ grain of atropine. 
Though there is no known antidote, the writer — in a case where half 
a cupful of the strong acid was taken in a fit of drunkenness — after 
the contents of the stomach were evacuated, washed that organ out 
repeatedly with pure glycerin, using half a gallon of it, the glycerin 
dissolving the excess of acid out of the swollen mucous membrane, and 
the patient made a good recovery. He has since satisfied himself that 
this is the best treatment whenever the strong acid has been swallowed. 

Chloral Hydrate. 

The stomach-pump or emetics, especially injection of apomorphine 
-j^o grain should be used, and these must be followed by injections of 



POISONING. 685 

strychnine (-fa grain) or of atropine (^ grain), caffeine (5 grains) or 
free stimulation with ammonia, whiskey, or ether, and sinapisms. Par- 
ticularly external warmth. Electricity and artificial respiration ; inha- 
lation of amyl nitrite may be tried. The patient should be roused and 
prevented from sleeping, and, as death may occur from the diminution 
of the body heat, warmth is essential. A pint of strong, warm coffee 
into the rectum, as advised by Murrell, may save life. 

Chlorine. 

Chlorine, when inhaled, must be treated by inhalations of ammonia 
of sulphuretted hydrogen. If the poison has been swallowed it should 
be neutralized by large quantities of albumin and mucilaginous drinks. 

Chloroform. 

When symptoms of an alarming interference with the breathing or 
circulation come on during anaesthesia, the tongue should be drawn 
forward, artificial respiration, cold affusion, free ventilation by a cur- 
rent of air, turning over the patient upon his left side, or inversion of 
the body, may be tried. 

Hypodermically — whiskey, ammonia, strychnine, or digitalis, or in- 
halation of nitrite of amyl, may be given. Galvanism is doubtful. If 
the chloroform has been swallowed, use the stomach-pump, or give -^ 
grain of apomorphine, and proceed as if inhaled. 

The following practical rules are appended to the recent report of 
the Hyderabad Commision, and the reporters state " that the Commis- 
sion has no doubt whatever that, if the rules be followed, chloroform 
may be given in any case requiring an operation with perfect ease and 
absolute safety, so as to do good without the risk of evil " : 

1. The recumbent position on the back and absolute freedom of 
respiration are essential. 

2. If during an operation the recumbent position on the back, cannot, 
from any cause, be maintained during chloroform administration, the 
utmost attention to the respiration is necessary to prevent asphyxia or 
an overdose. If there is any doubt whatever about the state of respi- 
ration, the patient should be at once restored to the recumbent position 
on the back. 

3. To insure absolute freedom of respiration, tight clothing of every 
kind, either on the neck, chest, or abdomen, is to be strictly avoided ; 
and no assistants or bystanders should be allowed to exert any pres- 
sure on any part of the patient's thorax or abdomen, even though the 
patient be struggling violently. If struggling does occur, it is always 
possible to hold the patient down by pressure on the shoulders, pelvis, 
or legs, without doing anything which can by any possibility interfere 
with the free movements of respiration. 

4. An apparatus is not essential, and ought not to be used, as, being 
made to fit the face, it must tend to produce a certain amount of 



686 poisoning. 

asphyxia. Moreover, it is apt to take up part of the attention which 
is required elsewhere. In short, no matter how it is made," it intro- 
duces an element of danger into the administration. A convenient 
form of inhaler is an open cone or cap, with a little absorbent cotton 
inside at the apex. 

5. At the commencement of the inhalation care should be taken, 
by not holding the cap too close over the mouth and nose, to avoid 
exciting struggling or holding the breath. If struggling or holding 
the breath do occur, great care is necessary to avoid an overdose 
during the deep inspirations which follow. When quiet breathing is 
insured, as the patient begins to go over, there is no reason why the 
inhaler should not be applied close to the face, and all that is then 
necessary is to watch the cornea, and see that respiration is not inter- 
fered with. 

6. In children, crying insures free admission of chloroform into the 
lung; but, as struggling and holding the breath can scarcely be 
avoided, and one or two whiffs of chloroform may be sufficient to pro- 
duce complete insensibility, they should always be allowed to inhale a 
little fresh air during the first deep inspirations which follow. In 
any struggling persons, but especially in children, it is essential to 
remove the inhaler after the first or second deep inspiration, as 
enough chloroform may have been inhaled to produce deep anaes- 
thesia, and this may only appear, or may deepen, after the chloroform 
is stopped. Struggling is best avoided in adults by making them blow 
out hard after each inspiration during the inhalation. 

7. The patient is, as a rule, anaesthetized and ready for operation 
to be commenced when unconscious winking is no longer produced 
by touching the surface of the eye with the tip of the finger. The 
anaesthetic should never, under any circumstances, be pushed until 
the respiration stops ; but when once the cornea is insentive, the 
patient should be kept gently under by occasional inhalations, and not 
be allowed to come out and renew the stage of struggling and re- 
sistance. 

8. As a rule, no operation should be commenced until the patient is 
fully under the influence of the anaesthetic, so as to avoid all chance of 
death from surgical shock or fright. 

9. The administrator should be guided as to the effect entirely by 
the respiration. His only object, while producing anaesthesia, is to see 
that the respiration is not interfered with. 

10. If possible, the patient's chest and abdomen should be exposed 
during chloroform inhalation, so that the respiratory movements can 
be seen by the administrator. If anything interferes with the respira- 
tion in any way, however slightly, even if this occurs at the very com- 
mencement of the administration, if breath is held, or if there is 
stertor, the inhalatisn should be stopped until the breathing is natural 
again. This may sometimes create delay and inconvenience with 
inexperienced administrators, but experience will make any adminis- 



POISONING. 687 

trator so familiar with the respiratory functions under chloroform that 
he will in a short time know almost by intuition whether anything is 
going wrong, and be able to put it right without delay before any 
danger arises. 

11. If the breathing becomes embarrassed, the lower jaw should be 
pulled, or pushed, from behind the angles forward, so that the lower 
teeth protrude in front of the upper. This raises the epiglottis and 
frees the larynx. At the same time, it is well to assist the respiration 
artificially until the embarrassment passes off. 

12. If by any accident the respiration stops, artificial respiration 
should be commenced at once, while an assistant lowers the head and 
draws forward the tongue with catch-forceps, by Howard's method, 
assisted by compression and relaxation of the thoracic walls. Arti- 
ficial respiration should be continued until there is no doubt whatever 
that natural respiration is completely reestablished. 

13. A small dose of morphine may be injected subcutaneously before 
chloroform inhalation, as it helps to keep the patient in a state of anaes- 
thesia in prolonged operations. There- is nothing to show that atropine 
does any good in connection with the administration of chloroform, and 
it may do a very great deal of harm. 

14. Alcohol may be given with advantage before operations under 
chloroform, provided it does not cause excitement, and merely has 
the effect of giving the patient confidence and steadying the circu- 
lation. 

Golchicum. 

Stomach-pump or emetics, mucilaginous drinks, albumin, or strong 
tea or tannin should be given, and these should be followed by a pur- 
gative, after which free stimulation may be required, and symptoms 
met as they arise. 

Oonium. 

The stomach-pump or emetics, tannin, and castor oil should be 
used. Stimulate freely by ammonia. Hypodermics of strychnine or 
atropine may be tried, and artificial respiration persevered with. 

Copper Salts. 

The stomach-pump or emetics must be resorted to if free vomiting 
has not occurred; yellow prussiate of potassium, egg albumin or milk, 
which form insoluble copper salts, are to be given ; mucilaginous 
drinks, and wheaten flour or water in which yolks of eggs are sus- 
pended, and the free use of opium to allay irritation, are called for. 

Corrosive Sublimate.— See Mercury. 



688 POISONING. 

Creasote. 

The same treatment may be employed as in poisoning by carbolic 
acid. 

Oroton Oil. 

The general treatment for irritant poisons may be used, viz. : Emetics, 
or, if in the early stage, the gentle use of the stomach-pump, demulcent 
drinks, soothing enemata, and opium. Free stimulation and counter- 
irritation may be necessary. 

Cyanide of Potassium. 

Poisoning is to be treated as if hydrocyanic acid had been swallowed, 
and if seen at once give solution of ferri sulph., and alternate hot and 
cold douche, while atropine is given by hypodermic injection. 

Digitalis 

The stomach-pump or emetics, especially sulphate of zinc, i drachm, 
or y 1 ^- or \ grain of apomorphine hypodermically, tannin, or animal 
charcoal, free stimulation, and the hypodermic injection of yt§ g ram 
of aconitine, and the free use of opium, are required. Muscarin (£ grain) 
is antagonistic, and alcohol should be given. 

The patient should be kept absolutely quiet, and in the horizontal 
position. 

Elaterium. 

Emetics or the stomach-pump must be used. Demulcent drinks and 
opium are to be administered freely, and the general treatment of the 
symptoms of gastro-intestinal irritation is to be followed. 

Eserine, or Calabar Bean. 

Emetics or the pump, with tannin or any tannin-containing liquid, 
may be employed, but hypodermic injections of atropine (-£■■$ grain), 
until the pupils widely dilate, afford the best chance. Strychnine and 
chloral have been recommended. 

Artificial respiration should be assiduously tried, with friction and 
warmth externally. 

Ether (Inhalation). 

Pull forward the tongue, give free current of air, commence artificial 
respiration, and treat as if chloroform poisoning. 

Fungi, or Muscarin. 

Emetics or the pump should be used, and atropine given hypo- 
dermically (g^o grain), and repeated until the pupils dilate, or digitalis 



POISONING. 689 

or morphine, may be given. Free stimulation, sinapisms, and friction 
may be required. 

The writer has had to treat a large school of children who had eaten 
fungi. Many were very bad, and about six of them appeared to be 
dying when first seen. Atropine appeared to act like magic, and all 
made a good recovery. 

Gelsemium. 

The stomach-pump and emetics are to be used, and bicarbonate of 
potassium and tannin freely given ; warmth, free stimulation with 
alcohol, electricity, and artificial respiration are to be kept up. 

Hypodermics of ammonia or atropine, or digitalis, are partially 
antagonistic. The best result will follow 3 minims of atropine solu- 
tion (1 : 100). 

Hydrocyanic (or Prussic) Acid. 

Antidote and treatment are described under Acid, Prussic. 

Hyoscyamus — Same as for Atropine. 
Iodine. 

Emetics or the cautious use of the rubber tube of the stomach-pump 
should be employed, together with the free administration of starch, 
arrowroot, bread, boiled potatoes, flour, lime-water, and demulcent 
drinks. 

Laburnum. 

The stomach-pump, if possible, should be always used, even if vomit- 
ing has occurred, as portions of seeds, etc., may remain in the stomach. 
Free stimulation, and, in bad cases, hypodermic injection of ammonia. 
Counter-irritation, friction, and the cold douche are necessary. 

Lead Salts. 

The stomach-pump, or, preferably, a large emetic of sulphate of zinc, 
which is also an antidote, should be given, and followed by milk, white 
of egg, diluted sulphuric acid, Epsom or Glauber's salts, or phosphate of 
sodium, sulphuretted hydrogen, or Harrogate water. Demulcent 
drinks, with mild opiates to allay pain and spasm, may be administered. 
(See also under Plumbism.) 

Lime. 

Carbonic acid — any aerated water, as soda water or lemonade — is 
very useful ; or weak acetic acid or vinegar, freely diluted, and fol- 
lowed by oil or demulcent drinks, may be swallowed. 



690 POISONING. 

Lobelia (or Tobacco). 

Emetics or the pump should be employed, as should also tannin, and 
free stimulation externally by sinapisms, friction, and dry heat, inter- 
nally or hypodermically by alcohol, ammonia, and ether, with strych- 
nine (-^q grain), and small doses of opium. The patient must be kept 
strictly in the horizontal position. 

Mercury (Corrosive Sublimate). 

Emetics, or the very cautious use of the pump will be required. 
(The pump should not be used except in the very early stages of the 
poisoning.) Albumin, or gluten (prepared by washing flour in a 
muslin bag), demulcent drinks, milk, and oil are to be given by the 
mouth, and morphine and alcohol, subcutaneously. 

Morphine.— See Opium. 

Muscarin (or Mushrooms). 

Same treatment as in poisoning by Fungi, viz., the subcutaneous 
administration of atropine after the use of an emetic or the pump. 

Nux Vomica.— See Strychnine. 
Opium (or Morphine). 

The stomach-pump, or, in its absence, emetics (if capable of swal- 
lowing), must be resorted to, or -^ to -J- grain of apomorphine injected 
hypodermically. The stomach should be washed out with tepid water, 
and filled with strong coffee or tea, or any infusion or liquid contain- 
ing tannin. 

Caffeine, atropine, or strychnine hypodermically, is to be adminis- 
tered. This latter should be repeated frequently as long as there are 
dangerous cardiac or respiratory symptoms ; y 1 ^ grain may be given 
every two or three hours. Flagellations, cold and hot affusions alter- 
nately, electricity, extensive sinapisms, or very hot water, to cause 
vesication in desperate cases, must be employed to rouse the patient, 
and when once aroused he should never be allowed to fall asleep 
again, but should be kept continually on the move, though every care 
must be exercised lest this should be carried too far so as to induce 
exhaustion, as is, unfortunately, often done. Artificial respiration may 
be required. 

Nitric Acid.— See under Acids, Mineral. 
Oxalic Acid. 

The pump or emetics must be used. Lime (lime-water, putty of 
lime, or chalk) is the best antidote ; one good dose of castor oil, coun- 
ter-irritation, free stimulation, and the treatment for gastro-enteric 
inflammation should be followed. 



POISONING. 691 

Pilocarpine. 

The stomach-pump or emetics will be required, together with the 
free administration of tannin and the hypodermic use of its antagonist 
— atropine — in -£$ to ^ grain doses. 

Phosphorus. 

The pump or emetics will be necessary. Sulphate of copper, 5 
grains every fifteen minutes, is both antidote and emetic. French oil 
of turpentine or any old oil of turpentine, purgatives, and demulcent 
drinks containing magnesia and albumin should be swallowed. Oils 
and butter should be avoided. 

Physostigma. — See under Eserine. 

Potash (Caustic). 

Emetics must be administered. The pump should not be used. 
Weak acids (vegetable preferred, and largely diluted), oils, and butter 
may be freely administered. The after-treatment will consist in rectal 
feeding, and after the danger of perforation has passed away, the free 
use of barley water, linseed tea, and other demulcents. 

Potassium Chlorate. 

The pump or emetics and profuse demulcent drinks and purgatives 
are indicated, along with hot blanket baths and the treatment for 
acute Bright's disease (page 72). 

Silver Nitrate (or Lunar Caustic). 

Large doses of common salt or sea water should be swallowed. 
Emetics and the pump (India-rubber tube) should be used, and white 
of egg injected into the stomach after the poison is removed. Yolk 
of egg, wheaten flour, or milk mixed with water should be freely ad- 
ministered. 

Soda (Caustic). 

Acids and oils will be require (as for potash). 

Stramonium. 

Emetics, tannin, free stimulation, and hypodermic use of morphine 
are the necessary treatment (same for atropine and belladonna). 

Strychnine. 

The pump or emetics, especially a hypodermic injection of ^ to | 
grain apomorphine, must be given, followed by charcoal or tannin 



692 polypi, 

in large quantities. Tobacco by rectum (with great caution — not 
more than 20 grains at once), bromide of potassium in large doses (2 
drachms to 2 ounces), chloral, chloroform, calabar bean, conium, mor- 
phine, ether, etc., are recommended. The writer believes that poison- 
ous doses of alcohol afford the best treatment given both by mouth and 
rectum. Artificial respiration may be tried. Chloroform inhalation 
may be kept up as long as the convulsions are severe. 

Sugar of Lead. 

Sulphate of zinc, albumin, etc. (See lead.) 

Sulphurets and Sulphuretted Hydrogen. 

Inhalation of air containing a small percentage of chlorine in it, 
and the free administration of a very weak solution of chlorinated 
lime or soda, constitute the necessary treatment. 

Sulphuric Acid. — See under Acids, Mineral. 
Tartar Emetic. 

Tannin, green tea, etc. (See Antimony.) 

Tobacco. 

Emetics, tannin, free stimulation, and hypodermic injection of 
strychnine (^ grain), are indicated, and the recumbent position must 
be strictly maintained (as for lobelia). 

Veratrine. 

The pumps or emetics must be used, followed by alcohol, opium, 
etc., as for aconite (which see). 

Zinc Salts (chiefly the Chloride, as Burnett's Fluid.) 

The rubber tube of the stomach-pump should be used with caution, 
or emetics, especially apomorphine, -^ grain, may be injected hypoder- 
mically. Egg albumin, tea, tannin, milk, alkalies or their carbonates, 
demulcent drinks, and soothing enemata containing a little laudanum, 
are to be administered. 

POLYPI. 

The treatment of these growths projecting from the various mucous 
surfaces of the body belongs to the province of the surgeon. Their 
removal may be effected in various ways. When the tumor is pedun- 
culated, and the pedicle can be grasped by a stout pair of forceps, 
and by torsion, avulsion, ligature, or section by means of the knife, 
scissors, Scraseur, or cautery, the growth may be safely removed. In 



polypi. 693 

the case of nasal polypi, if a cold wire-loop snare can be got around the 
pedicle or base of the growth by passing the snare along the floor of 
the nostril and adjusting the noose, there will be little difficulty in 
removing the polypus. More frequently, however, the part of the 
polypus which can be distinctly seen must be grasped by a fine pair of 
dressing forceps, and torn forcibly away from its attachments because 
the snare cannot be got around its base or pedicle by any artifice. In 
the firm, tough, or fibrous polypi springing from the roof of the nasal 
cavity, or from the bony prominences of the naso-pharynx, the best 
method of treatment is to use the wire of the galvano-cautery, and it 
may be often necessary to enlarge the opening of the nares to get 
thoroughly at the growth. Sometimes removal can be managed from 
the pharynx. The snare with pianoforte wire is always to be pre- 
ferred to the evulsion with forceps when possible, and when followed 
by the sparing use of chromic acid it appears upon the whole to be 
the best method of removing polypi from the nasal cavities. 

Baracz, by a comparatively simple operation, reaches polypi which 
cannot be removed by the forceps through the nose. After applying 
cocaine to the nose and lips he makes an incision through the lip 
immediately to one side of the middle line, and carries it up through 
the fleshy part of the nose on one side of the septum as far the nasal 
bones. If the growth be very large he cuts the nasal bone, and turns 
it aside with the flap of the skin, which, upon being forcibly retracted, 
permits of the nasal aperture being somewhat enlarged by bone for- 
ceps. Upon introducing one finger into the nostril and another behind 
the soft palate, the polypus can be easily enucleated by the finger-nail. 
He states that by this plan of operating, the entire nasal cavity, as far 
as the base of the skull, can be reached as effectually as in the more 
formidable operation of Langenbeck. There is little hemorrhage, and 
upon bringing the edges of the wound accurately together, only a 
linear scar remains. 

The medical treatment of nasal polypi is generally unsatisfactory, but 
occasionally a soft gelatiniform polypus springing from the turbinated 
bone may be caused to shrivel up and disintegrate by the continual use 
of a snuff consisting of finely-powdered tannic acid. Parker has em- 
ployed salicylic acid with advantage in the same way, and powdered 
sulphate of zinc or alum is sometimes successful. The spray of strong 
alcohol may be used, or various astringent solutions may be applied with 
a large camel's hairbrush, or the same solutions may be injected by the 
hypodermic needle into the growth, or, in more dilute solution, they 
may be used as nasal douches. Glycerin of carbolic acid (1:5) and 
solution of chloride of iron may be thus used. Ethylate of sodium 
solution may be efficacious if brushed over soft or even moderately 
fibrous polypi. Chromic acid fused upon a roughened probe is the 
best of all agents for touching small polypi. 

Though these methods of dealing with nasal polypi must be con- 
sidered as anything but satisfactory in the first instance, especially 



694 POLYURIA OR DIABETES INSIPIDUS. 

where the growths are within easy reach of the snare or polypus, 
nevertheless they are of great value as auxiliaries to the surgical 
measures. 

Thus, where clusters of soft polypi hang from the interior of the 
nasal walls the surgeon must often desist before he can feel confident 
that he has been able to seize and tear off all of them. Some will only 
be partially removed, and, owing to the hemorrhage, frequent sittings 
become necessary. Then, again, the pedicles may sprout up or the 
growths show a tendency to return. In such circumstances the tannin 
or salicylic snuff is of great value. 

When the surgeon can see the pedicle or base of the growth clearly 
it is the best practice to touch the stump or spot from which the poly- 
pus sprang with the galvano-cautery or chromic acid. 

Cocaine in all these performances is of the greatest value. Post- 
nasal growths are easily removed by the ring-shaped curette of Hart- 
man. 

In the case of uterine polypi, the ligature, torsion, snare, ecraseur, 
galvano-cautery wire, or excision by knife may be selected, according 
to the peculiar conditions maintaining in each case. Small polypi can 
generally be easily twisted off by grasping the pedicle in a pair of 
stout ovum forceps. When large, firm polypi grow from the ceiling 
of the uterus, rough or strong traction upon their pedicles, especially 
if these are short, may cause a portion of the uterus to become inverted 
and this might be included in the ecraseur if the surgeon was not upon 
his guard. This once almost occurred with the writer in removing a 
very large sessile polypus with the chain ecraseur. 

Where the polypus is sessile, and there is much danger of hemor- 
rhage, the wire of the galvano-cautery affords the safest and most effi- 
cient means of removing the growth. 

In the case of large intra-uterine polypi, after cutting through the 
pedicle the detached growth may refuse to be dragged through the 
cervix, as occurred to the writer in the case referred to. In this event 
the tumor itself may be caught in the middle by the ecraseur and 
divided, or the cervix may be dilated by Barnes's bags. 

Both these measures may be necessary in the first instance in order 
to reach the pedicle, and, if so, the method of rapid dilatation of the 
cervix by means of metal dilators is to be preferred. 

The strictest antiseptic precautions before and after the operation 
should be maintained, and the vagina and uterus should be first freely 
swabbed with a mop soaked in 1 part of tincture of iodine and 2 parts 
of glycerin, and afterward washed twice a day, or oftener, with solution 
of boric acid. 

POLYURIA OR DIABETES INSIPIDUS. 

This condition, depending upon very different causes in many in- 
stances, will be promptly relieved by measures at one timejWhich are 



PREGNANCY, DISORDERS OF. 695 

worthless at another. The treatment will become much more satisfac- 
tory when the pathology of the affection has been worked out. At 
present it is mainly empiric, and one remedy after another may be 
tried until the one which acts upon the unknown cause of the affection 
happens to be lighted upon. The most recent reports speak strongly 
in favor of antipyrine, and this drug can be administered at the same 
time that the older agents are being tried. The treatment of the affec- 
tion will be found detailed at length under Diabetes Insipidus upon 
pages 174 and 175. 

POST-PARTUM HEMORRHAGE (See page 315). 

POTT'S CURVATURE— See Caries of Spine (page 113). 

PREGNANCY, Disorders of. 

The most common departure, and the one most frequently calling 
for therapeutic interference, is morning sickness. As a rule, when this 
is but slight and does not tell upon the patient's condition, the less 
drugging the better. The bowels should be kept free, and this may 
be in most instances accomplished by attention to diet or by moderate 
doses of cascara, castor oil, or enemata of tepid water without soap. 
The diet should be such as is most speedily digested, and, though a 
dry dietary generally does best, some cases can only get on upon food 
which is liquid, as strong beef tea, champagne, iced coffee, koumiss, etc. 
The horizontal position in bed, maintained for several hours after the 
morning meal, often checks the vomiting. 

Of drugs and methods of treatment there is practically no end, and, 
as the plan which appears in one case to act as a charm may in the 
next prove useless, the physician will find himself driven to try one 
remedy after another until he finds the most efficient or until, as often 
happens, the vomiting stops spontaneously in spite of his exertions, for 
it cannot be denied that his exertions sometimes perpetuate the misery. 
It is, therefore, advisable to have a routine remedy which is perfectly 
harmless, and the following simple combination will be found of value 
in a surprisingly large number of mild cases : 

K . — Acid, hydrochlor. dil 5 iv. 

Tinct. aurantii amar ^j. 

Infus. gentianse ad ^viij. — M. 

S. — One tablespoonful to be taken in a little water three times a day. 

It may be given before or after meals, as the experience of the patient 
decides, and calumba may be substituted for the gentian. 

Tincture of nux vomica, in 5 to 10 minim doses, appears to act 
much in the same way as the above, and quinine occassionally proves 
useful also. Hydrocyanic acid, in doses of 2 minims, may be given 



696 PREGNANCY, DISORDERS OF. 

alone or mixed with either of these formulae, or it may be given with 
the following : 

Bismuth is a harmless drug and sometimes proves efficient. It may 
be given with the previously mentioned substance, or in combination 
with the following. 

Pepsin is sometimes efficacious, and where it fails in preventing 
vomiting, it may do good by hastening digestion so that the patient 
derives more benefit from the food before it is rejected. 

Ingluvin — a powder prepard from the gizzard of the common fowl — 
acts like pepsin, but is more frequently efficacious than this drug. It 
may be given in 10 grain doses every four or six hours, commencing 
before the patient leaves her bed for the day. 

A favorite combination consists of several of the foregoing remedies. 
It is often efficacious in relieving the vomiting of gastric ulcer and 
dyspepsia, but often fails completely in pregnancy : 

R • — Acid, hydrocyan. dil. . ... . . . 3 j. 

Morphinse hydrochlor. gr. jss. 

Liq. bismuthi (Schacht) % jss. 

Vini pepsinse . . . . . ad ^ iv. — M 

S. — One teaspoonful to be taken after meals three or four times a day. 

Morphine has met with some favor, especially when given as a sup- 
pository by the rectum or vagina, though the writer has found far 
better results from administering the minute pearls, each containing T ^ 
grain, by the mouth. Sometimes it proves effectual when given hypo- 
dermically. 

Oxalate of cerium has long maintained the reputation of being a 
specific in the condition under consideration, but the writer has been 
so uniformly disappointed with it that he seldom now uses it unless when 
most other remedies fail, and he finds then that it generally fails also. 
Three or 4 or even 8 grains may be given as a powder. 

Carbolic acid is sometimes useful, but creasote is much better, and 
may be given in the form of capsule. 

Salol in 2 grain doses acts in the samy way. 

Cocaine has recently been highly praised, but appears already to be 
losing some of its reputation. One quarter of a grain in solution may 
be given every two or three hours, and sometimes it acts more rapidly 
and effectively. One to 2 grains are sometimes given. 

Antipyrine and antifebrin have been recommended, but it is very 
doubtful if they exert any beneficial action. 

Paraldehyde in minute doses has been tried successfully in a limited 
number of cases. Three to 5 minims may be given every hour in 
syrup. 

Chloral hydrate is given, but it must be used with caution. Its best 
results have been obtained when given with the following : 

Bromide of potassium is very valuable, but it must be given in large 



PREGNANCY, DISORDERS OF. 697 

doses, and these sometimes increase the irritability of the stomach and 
are rejected. Hence the best method of giving the drug a fair trial is 
to give it in the form of an enema, combined with chloral. Gueniot 
uses 30 grains of bromide of sodium and 30 grains of chloral in 9 ounces 
of milk and water as a rectal injection. 

The following combination of some of the previously-mentioned 
drugs may fairly have a trial in a bad case : 

R. — Cocainse hydrochlor. . . . . . . gr. vj. 

Antipyrin 3Jss. 

Potassii bromidi 3 v. 

Inf. gentianse ad ,=f viij- — M. 

S. — One tablespoonful to be taken three times a day, before meals, in a little 
water. 

Aconite, given to the extent of producing its physiological effects, 
has been found by Wood to be often advantageous, though few will 
care to push a remedy of such potency so far. 

Liquor potassse, alone or combined with morphine, has sometimes 
given good results. Not more than 10 or 15 minims should be given, 
and the dose should be freely diluted. 

Calomel has been tried in small doses frequently repeated, so as to 
produce salivation, but the practice is not to be recommended. 

Tincture of iodine, Fowler's solution, and ipecacuanha wine have 
each been extolled, in doses of 1 minim diluted with water. Their 
effects are even more uncertain than most of the previously mentioned 
drugs. Tannin in 3 grain doses has occasionally proved useful. 

When, however, in spite of all drugs, the vomiting continues so as 
to seriously weaken the patient, emaciation with thirst, a hot skin, and 
red tongue show themselves, the situation becomes serious, and feeding 
by the bowel must be commenced aud steadily adhered to. Ice or 
ether spray to the epigastrium or sinapisms, if not before tried, should 
be applied and the patient rigidly confined to the horizontal position 
in bed. 

Should the weakness and emaciation proceed, the physician may 
ultimately have to induce premature labor, but before doing so various 
attempts may be made in order to counteract or correct any source of 
irritation which possibly may exist in the region of the uterus, ovaries, 
or vagina. Thus, flexions of the uterus have been proved to be a cause 
in some cases, and relief has been known to immediately follow the 
adjustment of a properly fitting pessary. 

Erosions, ulcerations, lacerations, or other abnormal conditions of 
the os or cervix, may be the exciting cause, and these may be treated 
by caustics, leeching, or suitable operations or applications. Cocaine 
in strong solution or in ointment, applied directly to the os, has 
stopped the vomiting in some cases; and a cotton-wool tampon satu- 
rated in glycerin has, by relieving congestion, removed the sympa- 

45 



698 PRESBYOPIA — PROCTITIS. 

thetic vomiting. The routine plan of applying strong nitrate of silver 
is to be condemned, but it may have a fair trial in severe cases before 
resorting to more serious measures. 

Electricity has undoubtedly proved efficacious in several cases, and 
if used with proper precautions is not at all likely to induce abortion. 
The positive pole is placed in contact with the os or cervix, while the 
negative is applied over the lower dorsal vertebrse, and a continuous 
current, registering from two and a half to five milliamperes, may be 
used for seven to ten minutes. Giinther, who recommends this treat- 
ment, points out the danger of producing abortion if the current be 
interrupted, and he urges the necessity for avoiding this. 

Copeman's plan may be tried before inducing labor. He recom- 
mended, and his practice has been successfully carried out by others, 
that the os should be dilated with the lower portion of the cervical 
canal. 

When all measures have failed to stop the vomiting, and when 
nutrient enemata have been unable to prevent marasmus, the last 
resource, after consultation with another physician, should be under- 
taken, and the uterus should be emptied by procuring abortion, or by 
inducing premature labor. It is, however, needless to say that this 
procedure will be rarely called for, even by those extensively engaged 
in obstetric work. 

The various other disorders of pregnancy are to be treated upon 
general principles, and need not be referred to here. Abortion has 
been dealt with under its appropriate heading, and albuminuria may 
be treated upon the lines laid down under its own heading or under 
Bright's Disease. Eclampsia will be dealt with under Puerperal Con- 
vulsions. 

PRESBYOPIA. 

The treatment of this condition can only be carried out by the 
use of proper convex glasses, which will enable the patient to read 
with comfort at about ten or twelve inches. It is a mistake to order 
strong lenses at first s and as the patient gets older the convexity of 
his glasses may be increased until he reads with comfort at nine 
inches. It may be necessary to correct both eyes for the same dis- 
tance, and many patients prefer to use stronger glasses when working 
by artificial light. 

PROCTITIS. 

Inflammation of the rectum is to be treated upon the same lines as 
are indicated in the treatment of other inflammation. The cause 
should be sought for, and treated or removed when present, and 
fissures, piles, fistulse, ulcers, gonorrhoeal pus, worms, or foreign bodies 
should be dealt with before permanent relief can be expected. More 
difficult are the cases (of which the writer has chanced to see several) 



PROLAPSUS ANI ET RECTI. 699 

where the proctitis is caused by discharge of pus from old abscesses or 
sinuses in the pelvis or in connection with disease of the vertebrae or 
pelvic bones. 

Warm poultices, hot fomentations, or hot sitz baths may be tried at 
first, after which, or while sitting in the bath, the rectum may be irri- 
gated by a stream of warm water. If arrangement is made for the 
return of the water, the injection can be carried out for considerable 
periods without dilating the inflamed bowel or exciting spasm in the 
sphincter. Iced water injections may be thus applied, and at a later 
stage antiseptic solutions, as boric acid, and, at later stages still, 
astringent injections may be thrown into the bowel. 

Under a previous heading the writer has pointed out the great value 
of conium (see page 47) as a rectal sedative, and the ointment of this 
drug, prepared as there stated, is of the greatest benefit. 

In very painful cases the juice of conium may be evaporated for a 
short period at a low heat, to expel any spirit contained in it, and 2 
drachms, or what would correspond to this amount of the fresh juice, 
may be injected with good result. 

Under Anus, Fissure of, page 46, the list of local sedatives has been 
discussed, and need not here be repeated. 

Where the pain and tenesmus are caused by the passage through 
the rectum of irritating discharges, the writer has used the following 
injection successfully, w T ith the view of shielding the inflamed mem- 
brane from irritation : 

Be. — Bismuthi subcarb ,^vj. 

Yitellum ovi 

Olei olivse ^ijss. 

Acidi carbolici gr. xxx. 

Aquae rosae . . . . . . .ad ^viij. — M. 

S. — Half ail ounce to be injected by a glycerin -syringe into the rectum when 
required. 

PROGRESSIVE MUSCULAR ATROPHY— See Paralysis (page 
587). . 

PROLASUS ANI et RECTI. 

The first thing to be done is to effect the return of the prolapsed 
anus or rectum. This is generally an easy matter, and by gentle 
pressure with the surgeon's fingers the mass is slowly pushed back 
until beyond the reach of the sphincter ; or the fingers of the patient's 
own hand, crowded together at their tips so as to form a cone, may 
be steadily pressed against the prolapse until it disappears. 

In the case of children there may be more difficulty, and some 
pressure may be needed to press out the blood from the prolapsed 
bowel, and to overcome the resistance and struggling of the patient, 
he may be placed across th? lap of the nurse, and his head depressed 



700 PROLAPSUS ANI ET RECTI. 

almost to the ground. A speedy method is to oil the right forefinger, 
and pass it into the bowel and press it upward as if making a 
rectal examination, and the prolapsed mass generally speedily 
retreats. 

A small pad of dry lint being placed over the anus, the nates may 
be strapped together by broad strips of adhesive plaster or a binder 
may be applied to the pelvis. 

Cripps effects reduction in bad cases by wrapping a piece of lint 
round the index-finger, and then inserting it into the protruded canal 
of the gut. As the finger is pushed upivard, the lint being dry, sticks 
to the mucous surface and assists reduction. After this has been 
effected the finger, which had been previously well oiled is slipped 
out, leaving the lint temporarily within the bowel. 

A warm injection of about 8 ounces of water before the bowels are 
moved, the passage of the motion while the patient is as far as possi- 
ble upon his side, and the injection of a very small quantity of very 
cold water afterward, was Brodie's method of dealing with all mild 
cases. 

The cause of the prolapse should be carefully investigated and 
remedied. This may depend upon such a number of abnormal con- 
ditions that the physician should explore the pelvic region with care. 
The most common cause in adults of prolapse of the anus of lower part 
of the rectum is hemorrhoidal growths, and, as already stated, when 
these are present the patient should be educated and warned to be 
certain to return the prolapsed mass after each evacuation. When 
the condition of the part warrants an operation for the piles, the pro- 
lapse is effectually cured by their removal. As a palliative remedy 
cold sponging, bathing, or cold water injections are most valuable in 
this as in most cases of prolapse. Worms when found should be ex- 
pelled by injections of a large teaspoonful of common salt, dissolved 
in half a tumblerful of water. 

Stricture of the urethra or rectum, enlarged prostate, a calculus in 
the bladder, or a polypus in the rectum or bladder, may be the cause, 
and the surgical procedures necessary to remove these causes will 
generally cure the prolapse. 

In the case of children many authorities are convinced that im- 
proved hygiene may do much. Where there is a marked emaciation, 
if this can be remedied the prolapse disappears, hence the necessity for 
good feeding and such agents as cod-liver oil. Cripps lays stress upon 
the importance of restoring the cushions of fat in the ischio-rectal 
fossse, the absence of which doubtless facilitates the descent of the 
bowel. The importance of attending to the bowels so as to prevent 
straining from constipation can hardly be exaggerated. Sulphur is 
the best laxative for this purpose. 

Small, irreducible prolapses, which have existed for a considerable 
time, may be removed in the same way as if they were a ring of pro- 



PROLAPSUS ANI ET RECTI. 701 

trading, internal piles. The continuous current has been used with 
success to restore the tone of the muscular fibres of the gut. 

Drugs have been used in chronic reducible cases in order to avoid 
the employment of surgical measures, and they sometimes are of great 
value. Thus, moderately strong solution of tannin, krameria or oak 
bark decoctions, injections of alum, chloride of lime, hydrastis, nitrate 
of silver and other astringents may be injected in small quantities. 
Ice may be likewise used, a piece as large as a plum being inserted 
occasionally beyond the sphincter. 

Ergot has, however, given much better results than any other drug. 
It is, however, more suitable in cases where the rectum is involved, 
but may be used in chronic anal cases. One, two, or three grains of 
extract of ergot (ergotine) should be injected, as originally suggested 
and carried out by Vidal into the prolapsed bowel. Glycerin 
injections (2 drachms) have proved very efficacious in the prolapse 
following the diarrhoea of children as shown by Rice. 

A pad of lint, or a small, inflated rubber pad, or a plug may be 
necessary in chronic cases where a considerable amount of rectum is 
prolapsed. These may be fastened by a T-bandage or by tapes 
attached to the shoulders. 

Brushing over the prolapsed anal mass by strong nitric acid is a 
very severe and may become a serious measure, but often it is a highly 
efficacious method when the anus only is involved. It is perfectly 
safe if the acid be applied in limited amount, as in the operation of 
linear cauterization. 

The actual, or thermo-cautery may be used with great advantage 
in anal and in slight rectal prolapses, the iron being lightly drawn 
along the prolapsed membrane in a linear fashion. 

Cripps prefers this method to all others in most cases. He operates 
with the patient in the lithotomy position, making four lines with the 
actual cautery by drawing the iron along the bowel in its long axis, 
one in front, one behind, and one on either side. These lines begin as 
high up as possible, and terminate at the anal margin. They should 
be about I inch in width, and deep enough to sear thoroughly, but not 
to destroy the mucous membrane. Where the lines cross large veins, 
these should be tied on either side of the line with a Liston's needle. 
The bowel should be returned quickly, a strong rubber tube of J inch 
calibre and 7 inches long is passed into the rectum, and the space be- 
tween it and the mucous membrane is to be packed all round with 
cotton wool, dusted with iodoform, the mucous surface being first pro- 
tected by strips of oiled lint. Flatus finds an easy exit through the 
tube, while an even pressure is kept up. The rationale of the treat- 
ment is to excite inflammation in the submucous tissue, so as to bind 
the mucous and muscular coats together in order to prevent the 
initial slipping, which is the chief cause of the affection. 

Excision of portions of the prolapsed mucous membrane may be 
performed so as to lead to contraction after cicratrization. 



702 PROLAPSUS UTERI. 

Curling recommends that in adults the anal aperture should be con- 
tracted, and the fall of the rectum prevented by the application of the 
mineral acids or by caustic potassium applied to the mucous membrane 
at this juncture with the skin. This does not seem to the writer to be 
as likely to result in permanent relief as linear scarification or removal 
of strips of the mucous membrane. 

In very severe cases where a considerable portion of the rectum is 
constantly prolapsed, the best procedure is to dissect up and remove a 
broad flap of mucous membrane from the surface of the prolapsed 
bowel, the margins of the mucous membrane are then to be brought 
together by sutures so as to very considerably reduce the dimensions 
of the bowel, a second or third flap may be dissected off at opposite 
aspects, and the same plan of bringing together the margins of the 
gap left after dissection of the flap is to be carried out. The operation 
may be followed by alarming hemorrhage, and most careful after-treat- 
ment as for operations for extensive haemorrhoids is requisite. 

In still more serious cases circular resection of the gut may be per- 
formed, and Milkulicz has successfully resected two and a half feet of 
the prolapsed colon. McLeod has introduced an ingenious but heroic 
operation by which he fastens the upper end of the rectum to the ante- 
rior abdominal wall by a double series of silk ligatures passing through 
the mucous and serous coats of the bowel. Treves treats bad cases 
with an excision operation, which he has described in the Lancet of 
March, 1890. 

PROLAPSUS UTERI. 

As a rule, there will be no difficulty in replacing the prolapsed 
organ as the patient lies upon her left side or in the genu-pectoral 
position, steady, gentle pressure sufficing to restore the uterus to its 
normal position in the pelvis. Sometimes, where complete procidentia 
exists, it may be found difficult to accomplish this without resorting to 
the use of considerable force, which is not justifiable under these cir- 
cumstances. The patient should be put to bed for a few days, when 
the rest will be found to have materially diminished the weight and 
size of the organ, so that steady pressure directed in the axis of the 
outlet, and afterward in the axis of the body of the pelvis, effects re- 
duction. 

In mild cases prolonged rest and the frequent use of astringent in- 
jections, such as the cold saturated solution of alum or decoction of 
oak bark, will often prove efficacious. It is a mistake to think that 
nothing can be done without inserting supports. Many cases, even 
where the organ has been long prolapsed, may be permanently cured 
by absolute rest for several days and the daily use of astringent lotions 
afterward, together with such measures as will reduce the size and 
weight of the enlarged or congested organ. The bowels and bladder 
must be regularly relieved. 



PROLAPSUS UTERI. 703 

A large tampon of absorbent cotton wool, soaked in glycerin 7 
parts, and borax 1 part, and inserted into the vagina, where it may be 
kept for forty-eight hours, has a rapid action in reducing hyperemia. 

Tonic remedies, such as iron, quinine, and strychnine, internally, 
and sea bathing, with periods of absolute rest upon a hard sofa for 
several hours during the day, are not without their beneficial influ- 
ence. 

Where the bladder or anterior wall of the vagina prolapses, the 
patient should be instructed to pass water when resting upon her knees 
and elbows, and the physician should see that the daily regular use of 
the vaginal douche every eight hours is conducted efficiently and 
thoroughly. Thus a long vagina pipe should be used, and a copious 
stream of cold, or almost cold, water should be injected for three or 
four minutes, until all traces of mucus or discharge are washed away, 
after which a quart or more of the cold saturated solution of alum is 
injected. The continuous current is often beneficial in restoring the 
tone of the relaxed structures. 

The pressure of tight clothing around the waist or pelvis must be 
avoided, and where the abdomen is very pendulous, a neatly-fitting 
abdominal belt, constructed by a skilful corset or truss maker, may be 
worn with advantage. 

Some patients who cannot wear pessaries manage to keep themselves 
comfortable by the daily introduction of plugs or tampons of cotton 
wool inserted into the vagina, and removed at bed-time. 

Where the above measures fail to give support, and the uterus con- 
tinues to fall downward, there should be an attempt made to keep the 
organ up by means of a pessary. 

Of these the variety is endless, but the physician should aim at the 
selection of a support which will not destroy the remaining elasticity 
or contractility of the vagina, or unduly stretch the uterine ligaments. 
Hence the old solid, globular, boxwood pessaries should not be selected, 
and the same objection applies to the thick boxwood ring or gum 
elastic ring instruments, though the writer has succeeded in keeping 
the uterus in position with these latter after failure with every other 
instrument. The elastic ring is often satisfactory where the vagina is 
very capacious, and those slender instruments containing a spring em- 
bedded in the rubber are to be preferred to the weighty thick rings of 
pure rubber. In mild cases, or where there is a good perineum, a 
well-fitting Hodge is by far the most satisfactory form of support, and, 
though it often may be disappointing by slipping out, when a suitable 
shape and size is selected which remains in situ there is generally 
nothing more to be desired. 

Greenhalgh's elastic spring with cross bars or Galabin's vulcanite 
instrument may be found to succeed where Hodge fails. The former 
is indicated when the bladder tends to prolapse. 

Where the procidentia is complete, and the perineum useless as a 
support, the cup and stem pessary of Barnes will generally prove satis- 



704: PROLAPSUS UTERI. 

factory. The neck of the uterus sits or lies in the cup, and the stem is 
supported from below by a wastband and perineal straps. There are 
various modification of this instrument, one of which is intended to be 
retained in the vagina without supports, but it generally falls out. 
Cutter's ring pessary acts upon the same principle at the stem instru- 
ment, and it is retained in position by a rubber strap attached to a 
waist belt. 

Zwank's pessary sometimes keeps the uterus in position when all the 
above fail, but the writer has found that it so very often breaks and 
gets out of order that it would be almost necessary for the patient to 
permanently retain, the services of an instrument maker. Its blades 
should be inserted, closed, and then screwed out when in the vagina. 
It should be taken out generally at night, and inserted before getting 
up in the morning. If left in position for long periods, serious ulcera- 
tion may be set up. 

Gynecological massage and gymnastic exercises, according to Brandt's 
method, are said to be of the greatest use in prolapse, but Macnaughton 
Jones has entered a strong protest against this method, with which the 
writer heartily concurs. 

Where the above palliative measures fail, or where, for special rea- 
sons, a more permanent or radical cure is desired, various surgical 
measures have been recommended and practised with varying success, 
the special operation being selected which, on account of the ana- 
tomical condition of the parts, appears to give the best prospects of 
success. 

The operation of building up a new perineum where this part has 
been ruptured or destroyed in previous labors, is a rational procedure, 
and though it may fail to cure the prolapse, it generally succeeds in 
leaving the parts in such a condition as will enable the physician to 
most successfully remedy the displacement by a well-adjusted Hodge's 
pessary, which was not possible before. If this end can be completely 
gained, the physician may rest satisfied, unless the patient insists upon 
a more radical procedure. Sometimes, however, a new perineum can- 
not be made, and the number of operations which have been suggested 
to cause narrowing of the vaginal canal, or to produce lateral, or ven- 
trofixation is beyond narrating in the space at our disposal. 

Asch, as in eight cases, recently extirpated the uterus and resected 
the vagina for complete relapse; Others have been content to remove 
a portion of elongated cervix. 

The operations of Simms and of Emmet, whereby a narrowing of the 
vagina is accomplished by the removal of flaps of mucous membrane 
from its anterior surface, or posterior colporrhaphy, which aims at the 
same object by removing portions of the posterior vaginal walls, may 
be adopted. 

Pean passes a double row of sutures along each side of the vagina 
through the recto- vaginal septum and the vesico- vaginal septum respec- 
tively. 



PROSTATE, INFLAMMATION OF. 705 

Simon's operation is an excellent one in some cases. He pares the 
surfaces of the posterior aspects of the labia majora and the neighbor- 
ing tissues at the vaginal outlet, and after bringing the surfaces together 
by deep and superficial sutures, the perineum is thus greatly length- 
ened, and the uterus imprisoned. 

Various methods have been suggested from time to time for the 
occlusion or contraction of the vaginal canal by employing caustics, 
or the cautery ; other means by mechanical pressure, so as to cause 
sloughing and subsequent cicatrization of the ulcerated or eroded sur- 
faces have been tried, but these methods are now seldom resorted to. 

Phillips points out the different ways in which ventral fixation of 
the uterus to the anterior abdominal wall by abdominal section and 
suturing of the organ or its appendages may be carried out, viz. : 1. 
By hysterectomy — removing the uterus and bringing the stump into 
the abdominal wound. 2. Removal of both ovaries and appendages, 
and suturing one or both stumps into the abdominal wound. 3. Su- 
turing the round ligaments as they pass obliquely from the uterus, and 
bringing the stitches out external to the median incision. 4. Hysteror- 
rhaphy — bypassing stitches through the muscular tissue of the fundus. 
5. Removal of the appendages on one side only and suturing the stump, 
not into the wound, but external to it, by making the stitches pierce 
the abdominal wall, adhesion between the stump and parietal perito- 
neum being the object to be attained. 

PROSTATE, Inflammation of. 

While soothing remedies are being employed for the relief of the 
prostatitis, the cause of the attack should receive attention. Thus, 
gonorrhoea, cystitis, or an impacted calculus must be met by appro- 
priate remedies. Absolute rest in bed, except when the patent is sit- 
ting in a sitz-bath, is essential. The bowel should be cleaned out by a 
copious warm water enema, and by a little ingenuity a stream of warm, 
hot, or ice-cold water may be made to irrigate the lower part of the 
bowel, the temperature of the water depending upon the sensations of 
the patient. Hot poultices or warm fomenations, or a large piece of 
ice occasionally introduced into the rectum, act beneficially upon the 
same principles. 

Leeching the perineum is sometimes very successful in relieving pain, 
and a small cupping-glass may be applied over the bites, or warm 
fomentations to encourage the bleeding, may be tried. 

Where there is smart urethral irritation, gleet, or gonorrhoea, the 
frequent injection of hot or warm water down the passage does good, 
but astringent or irritating injections are to be forbidden. 

The occasional administration of a large saline purgative is most 
beneficial, and the following mixture may be given in acute cases with 
benefit : 



PROSTATE, 


HYPERTROPHY 


OF. 






Morphinse hydrochlor. 
Potassii acetetis 














gr. jss. 
3iv. 




Tinct. hyoscyami 
Vini antimonii 


















Liq. arumonii acetatis 












ad 


I'iy.- 


-M 



706 

R 



S. — One teaspoonful to be taken in half a cupful of fresh barley water four 
times a day after meals. 

Morphine, by the rectum, in the form of suppository, is always indi- 
cated for the relief of pain. Should signs of suppuration occur, and 
fluctuation be distinct, the abscess may be aspirated or punctured by a 
sharp knife through the rectum, or a free, very deep incision may be 
made in the perineum with a staff in the urethra, or the left index- 
finger being placed in the rectum, a double-edged knife may be thrust 
deeply into the tissues in front of it until pus is reached. Prostatic 
calculi, if present, should be removed through the incision, and the 
wound must be daily syringed with an antiseptic solution, and drainage 
established, if necessary. 

In chronic inflammation of the prostate, cold sitz bath, cold enemata, 
counter-irritation by means of small blisters to the perineum, and the 
passage of a soft rubber catheter smeared over with unguentum conii, 
so as to draw off the urine when necessary, and the occasional injection 
of 5 to 10 minims of caustic solution (1 : 20) to the deep part of the 
urethra are to be employed. Internally, small doses of boric acid, in 
conjunction with moderately large doses of tincture of hyoscyamus 
and ergot may be used. 

While attention and treatment are directed to the cause of prostatitis, 
where this is owing to the following condition, the surgical and medical 
treatment to be presently detailed must be patiently carried out. 

PROSTATE, Hypertrophy or Enlargement of, 

Requires varied and very skilful management according to the stage 
of the disease, and the extent of the enlargement. Cystitis and reten- 
tion of urine, the former depending upon or resulting from the latter, 
will require constant attention. 

In cases where the enlargement of the gland only leads to a small 
amount of urine being left in the bladder after the patient thinks he 
has quite emptied himself by micturition, the symptoms are consider- 
ably masked, and the surgeon may long imagine that he has only got 
a simple case of cystitis to treat. The decomposition of the residual 
urine sets up grave, local, and constitutional symptoms, and if not 
promptly and judiciously met, a fatal result too often follows. 

In such cases a full diagnosis of the situation is absolutely necessary, 
and this is comparatively easy. The finger in the rectum will ascertain 
the presence of the enlarged organ, and the age, generally over fifty- 
seven or sixty years, will furnish strong and almost conclusive evidence 



PROSTATE, HYPERTROPHY OF. 707 

of the nature of the enlargement. If the patient is now made to empty 
his bladder as completely as possible, the passage of a soft rubber 
catheter immediately afterward will demonstrate the amount of residual 
urine left after micturition. 

If the quantity of urine is comparatively small, amounting to under 
3 or 4 ounces, the general surgical rule is that the patient should at once 
enter upon catheter life, and henceforth draw off the urine once or 
twice or oftener every day, remembering, however, that the mischief is 
mainly, if not entirely caused, not by the amount of residual urine left 
constantly in the bladder, but to the changes which sooner or later are 
set up in the retained fluid. If any means could be obtained where- 
by these changes could be effectually prevented the patient's life need 
not, in mild cases, be subjected to the risks and dangers which some- 
times follow the daily use of the catheter. 

Since the above sentence was written, Reginald Harrison has stated 
his belief in the necessity of having some residual urine always in the 
bladder, which in this class of cases has ceased to be able to become a 
closed space after all the urine has been withdrawn. He emphasizes 
the opinion that the residual urine should only be withdrawn by the 
catheter when there is evidence that either by its quantity or its quality 
it is doing positive harm to the individual, He believes that the 
sudden and complete emptying of the bladder in these cases has every- 
thing to say to the setting up of the so-called catheter fever. 

Until within a comparatively recent date therapeutics did not fur- 
nish any reliable and safe means for disinfecting the residual urine, 
and the above surgical law could not be neglected with safety. 

Perez, however, found that boric acid when given internally, checks 
putrefactive changes in the urine; and the writer' has found in scores 
of cases that a few daily doses of 10 to 15 grains of this drug very 
speedily after the character of fetid urine in chronic bladder affections 
— (see page 68). In many instances he has found that all the symp- 
toms of bladder irritation rapidly subsided after beginning such treat- 
ment, and the high-smelling decomposed secretion which was passed on 
micturition, gave place to a healthy and sweet secretion, and in several 
cases as the irritation of the bladder subsided, this organ has so recov- 
ered its tone and power that it was able to completely evacuate its con- 
tents, notwithstanding the continuance of the enlargement of the pros- 
tate. The cystitis necessitating frequent and fruitless attempts to mictu- 
rate, increases considerably the prostatic trouble by grafting upon the 
hypertrophy a congestive or inflammatory condition of the enlarged 
gland. This relief is sometimes, though rarely experienced after begin- 
ning catheterization, which so relieves the irritability of the bladder and 
prostate, as to enable the patient to leave off its use for a long period, 
and in some very exceptional cases, for the remainder of his life. 

With these facts one is often justified in postponing obedience to the 
above law, and always in mild or recent cases the patient may safely 
have the benefit of the chance. Where the hypertrophy continues to 



708 PKOSTATE, HYPEETKOPHY OF. 

advance, and the amount of residual urine increases, and especially 
when occasional retention supervenes, there is little use in trusting to 
the simple procedure of rendering the urine aseptic, while grave struc- 
tural alterations may be slowly taking place in the bladder, ureters, 
or kidneys, owing to the increased pressure caused by obstructed flow. 

Under these circumstances catheter life must be entered into seri- 
ously, though occasionally the patient may find that he sometimes is 
rewarded by such an improvement or amelioration in his symptoms as 
will enable him for a time, at all events, to lay the catheter aside. In 
advanced cases, of course, this never happens. Harrison has proved 
the advantages which follow persistent dilatation by means of a dilator 
designed for the purpose. 

The best catheter for use is the soft vulcanized rubber. When the 
bladder can be entered by it, the almost invariable advice is given to 
lubricate and keep this free from germs by carbolic oil. 

Oil so acts upon the rubber as to render it brittle or " tearable." and 
it also destroys its polish. Hence it never should be employed. 

For many years the writer has recommended glycerin of borax (made 
without the addition of water). This is an excellent lubricant, and 
preserves the rubber in good condition, and it is fatal to all germs. It 
consists of borax 1 part, and glycerin 4 parts. 

The patient should be taught to use the instrument himself at regular 
and stated times. Where the rubber fails to worm its way along the 
urethra a plain English gum-elastic catheter, without a stylet, may be 
used. Large sizes should always be employed. The French coude is a 
favorite instrument, but the Belfast linen catheter is coming rapidly 
into favor. Harrison points out the great importance of not having an 
instrument of large calibre, which empties the bladder too rapidly. 

The bowels should be kept constantly free, constipation being always 
injurious. Food, exercise, and drugs are to be employed as circum- 
stances demand. The occasional use of boric acid (10 grains every 
morning) and of cascara sagrada (one dose at bed-time) is often all the 
medicine required. 

The following mixture may be used to give tone to the vesicular coats, 
and to diminish irritability and keep the urine aseptic : 

R. — Tinct. nucis vomicae . . . . . . £iv. 

Acid, borici ^ij. 

Tinct. belladonna 3J- 

Tinct. hyoscyami ^ij. 

Infus. buchu . ad ^ x. — M 

S. — One tablespoonful to be taken three times a day after meals, in efferves- 
cing potash water. 

Washing out the bladder — a constant practice with some surgeons — 
will be rarely, if ever, required, when the virtues of boric acid inter- 
nally have become universally appreciated. 

Under exceptional circumstances a stream of any unirritating weak 
antiseptic solution may be passed through the bladder by attaching a 



PROSTATE, HYPERTROPHY OF. 709 

few feet of small rubber tubing to the rubber catheter (making the 
joint with a small piece of glass tubing). Into the free end of the tubing 
a small glass funnel is inserted. By this simple contrivance the bladder 
may be washed out by the patient himself at any time. In some cases, 
where a catheter must be left in the bladder, the softer rubber instru- 
ment is the best, and Browne advises that a leaden stylet is perfectly 
safe, and it will be found to prevent doubling up of the rubber. 

The great majority of cases manage to exist with very little discom- 
fort under the conditions imposed by catheter life ; but occasionally 
even the catheter fails to give relief, and may be passed with difficulty, 
and when the patient appears to be wearing out with incessant pain 
and calls to micturate, further surgical interference is demanded. 

This must point in the direction of incision into the bladder, and the 
establishment of such efficient drainage as will give the bladder abso- 
late rest for a time by allowing the urine to flow through it as it trickles 
from the ureters. 

Numerous operations are practised, the boldest of which is that suc- 
cessfully practised by McGill, Kummell, G. B. Browne, Mayo Eobin- 
son, and many others. This is gaining rapidly in favor, and consists 
in a partial extirpatien of the gland after opening the bladder above 
the pubes. The operation is known as McGill's supra-pubic prostatec- 
tomy. 

After opening the bladder the projecting portion of the prostate is 
removed from the inside by the scoop and finger. Kummell uses the 
thermo-cautery for its destruction. After a short time complete relief 
follows the operation, and the great majority of the cases never after- 
ward require the use of the catheter, the power of micturating being 
established for the remainder of their lifetime. The supra-pubic open- 
ing seldom remains open for any length of time. During the opera- 
tion the inverted position of the patient should be adopted, and after- 
ward the bladder wound should only be partially closed by sutures. 
The best dressing consists in the free use of wood-wool pads. 

Other measures less formidable in appearance, though not so satis- 
factory in their ultimate results, are recommended, but none afford the 
same chance of permanent recovery. 

Whitehead establishes a permanent perineal opening after a median 
perineal urethrotomy. Through this a drainage-tube may be worn, or 
a catheter passed. McGuire establishes a permanent supra pubic 
urethra. A permanent supra-pubic fistula and the constant use of a 
drainage-tube may be tried. The various methods of tapping the 
bladder by the rectum are not to be recommended, nor is perineal 
cystotomy to be advocated. 

The various methods of removing portions of the enlarged gland 
through the perineum appear to afford fewer advantages than McGill's 
plan, and they will probably continue to be employed only under 
special circumstances. 

Belfield, in a valuable contribution, has recently reviewed the sue- 



710 PRURIGO. 

cesses and failures of the operative treatment of enlarged prostate, and 
dwells upon the published cases where McGill's supra-pubic pros- 
tatectomy had failed to remove the growth, and he predicts that the 
operation of the future will be McGill's operation, or a supra-pubic 
cystotomy along with a perineal incision, permitting of the stretching 
and exploration with the finger of the prostatic urethra. 

PRURIG-O. 

The treatment of this affection is most obstinate, and in. the severe 
form described by Hebra it is almost hopeless. 

Prurigo senilis, as maintained by Pye-Smith and other dermatologists, 
is only phthiriasis. This is rapidly cured by the specific treatment 
mentioned under Pediculi, page 588. 

For the ordinary forms of true prurigo, internal remedies, the best 
of which is cod-liver oil, are necessary. Every measure which increases 
the constitutional vigor and strength of the patient should be persisted 
in for long periods. Arsenic, iron, phosphorus, and quinine are drugs 
which, along with cod-liver oil, may be given for one or two months in 
rotation. Small doses of bichloride of mercury, say -g 1 ^ grain, may be 
advantageously given for a fortnight or a month after the temporary 
suspension of the above remedies. Over-feeding, when possible, should 
be aimed at. 

Some benefit has been obtained by the hypodermic injection of small 
doses of pilocarpine, of ergot, and, according to Shoemaker, of i to £ 
grain of hydrochlorate of cocaine. 

Local treatment is of considerable importance, and, if carried out 
with patience and perseverance, the disease may be kept in check in 
the worst cases, and even in severe cases may be ultimately banished. 
In children, the management and removal of the disease are, for the 
for the most part, not difficult. 

Warm baths should be given frequently, and these may be made 
alkaline by adding about half a pound of bicarbonate of sodium to a 
large bathful of water, or soft soap may be used, the object being to 
get rid of the increased growth of superficial cutaneous cells which 
have become dry and dead. After each warm bath, and as much 
gentle friction as will, without increasing the irritation, cause the 
removal of the loose layers of the cuticle, the patient's body should be 
well dried, and an animal fat should be thoroughly rubbed in. If this 
be carried out every night for a considerable period, it is surprising 
how soon the prurigo will show signs of yielding. Lard, cod-liver oil, 
and lanolin are the best substances for inunction. The latter is 
preferable if the patient can get over its disagreeable stickiness. Cod- 
liver oil is valuable, but its disagreeable odor, which increases after it 
has become mixed up with the dried scales on the surface of the body, 
is a great barrier to its use, but in the case of children it certainly is 
the best remedy. 



PRUKITUS. 711 

Gradually the animal fats may be laid aside for an anointing oil, 
consisting of pure almond oil, 9 parts, and oil of cade, 1 part. Naph- 
thol has been well spoken of. 

Scratching is to be avoided in every possible way, and in the case of 
children woollen gloves should be tied on the hands to prevent injury 
by the finger nails. Any eczema caused by scratching will require 
appropriate treatment, and when the pruritus is very distressing any of 
the remedies mentioned in the following article may be tried. Seda- 
tives at night may be needed, but opium should not be given. 

PRURITUS 

is constantly mixed up with the above affection, and there is, conse- 
sequently, much difference of opinion and confusion about the manage- 
ment of cases. Accepting pruritis as a sensation of continual itching, 
without the presence of the papules characteristic of prurigo, the first 
step in its treatment will be to remove any cause, when this can be 
made out. Diabetes, gout, B right's disease, jaundice, dyspepsia, and 
other ailments may be the direct cause, and will afford the true indica- 
tions for correct treatment ; while, upon the other hand, various local 
causes may be at work, and these should invariably be looked for 
diligently. Thus, pediculi, scabies, ringworm, and the irritation pro- 
duced by certain woollen fabrics, may be the cause, upon the removal 
of which the pruritus rapidly disappears. In other cases it appears to 
depend upon a neurosis, and must be met by remedies which will tend 
to depress or blunt the exalted sensibility of the fine nerve endings in 
the skin, as bromide of sodium in large doses, cannabis indica, tincture 
of gelsemium, pilocarpine, atropine, ergot, and other drugs. 

Shoemaker, who has published valuable researches upon the treat- 
ment of pruritis, has obtained excellent results in cases characterized 
by anaemia and debility, by the hypodermic administration of cod-liver 
oil, in daily doses of 1 to 2 drachms, injected into the subcutaneous 
tissues of the back. At the same time, and in all cases, electricity and 
massage may be relied upon to improve the general condition and afford 
comfort. Mild local faradization with central galvanism he finds most 
effective in nervous, prostrated patients. He states " that the electric 
treatment, combined with proper internal medication, has in my hands 
ameliorated the condition of many to whom life itself, under the horri- 
ble attendant sensations, had become a burden, and has, in very many 
instances effected a permanent cure after all other treatment had 
failed." 

Baths are of the greatest service. The warm alkaline bath, contain- 
ing about 8 to 12 ounces of bicarbonate of potassium, generally affords 
temporary relief, and if used before a good half-hour's general massage 
its effects are often very marked at bed-time, inducing sleep. Sulphuret 
of potassium has been used as a bath and found very beneficial, though 
the writer has generally found it to aggravate matters, owing to the 



712 PRURITUS. 

very common traumatic eczema jinduced by previous scratching. 
Nearly every one of the numerous sedative baths used in the practice 
of skin therapeutics affords more or less relief from the sensation of 
itchiness. The starch bath is a favorite, and after coming out of it the 
skin may be dusted over with the dry powder, mixed with salicylic 
acid (1 : 25). 

Of drugs for local application, menthol is the most reliable. It may 
be used in innumerable ways. Saalfeld dissolves half a drachm of 
menthol in H ounce of pure spirit of wine, and this may be painted 
over the affected region in the same way as the writer has brushed the 
oleum menthse piperita with a camel's-hair brush. 

Two drachms of menthol rubbed up with ^ ounce of olive oil and 
1 drachm of chloroform may be made into an ointment with 2 £ ounces 
of lanolin. 

Cocaine has been extensively employed with success. The ingenious 
method of Porritt is the best where the region affected is of limited 
extent. He uses a cone of cacao butter impregnated with 2 per cent, 
of cocaine. As this is rubbed over the irritating patch the warmth of 
the skin melts the butter, which forms a soothing, emollient shield 
over the irritable nerve endings in the skin. 

Machiavelli combines various drugs with the cocaine. The following 
is an elegant and valuable formula where the itching is bad at night : 

R . — Cocaine purif. gr. iv. 

Hydrarg. ammon gr. xv. 

Zinci oxidi gj. 

Vaselini albi gx. — M. 

Carbolic acid is often useful. A 1 in 80 lotion may be sponged over 
the skin at night, or carbolic oil (1 : 20) may be smeared over the body 
at bed-time, or any firm ointment may be employed. Lanolin, which 
alone is an excellent sedative in pruritis senilis, may be combined with 
the carbolic acid. 

Creasote is better than carbolic acid, and the following simple com- 
bination is excellent : 

R . — Creasoti (beechwood) ^j. 

Lanolini ^ij. — M. 

The previously mentioned authority recommends carbolate of sodium 
in persistent itching of the female genitals, in the following form : 

R .— Sodii carbol. . 25 grammes. 

Eau de Cologne . 75 " 

Glycerini 100 " 

Aquse dest 300 .— M. 

This may be followed in bad cases by compresses soaked in the 
following : 



PRURITUS. 713 

K . — Cocainse kydrochlor 75 ceatigrammes 

Alcoholis 100 grammes. 

Aquae dest 300 " .— M. 

Verrier for the vulva used the following, applied in the form of 
tampons in obstinate cases : 

R 



-Acid, carbolici 


• gr-ij- 


Morphinse acetatis . . . 


. . . gr. jss. 


Acid, hydrocyanici dil. . 


. . . . mxij. 


Glycerini purif. 


. . . . Ttl±L 


Aquse dest 


. • . . Ij.-M 



The proportion of carbolic and hydrocyanic acids is quite too 
small to be of much use in this mixture ; it may safely be largely 
increased. 

Julien uses the following in pruritus vulvae : 

R. — Acidi salicylici gj. 

Zinci oxidi purif. ^iij. 

Glycerini amy li ^iij* — M. 

The same measures may be employed for pruritus ani ; but as this 
depends so often upon the presence of haemorrhoids, fissures, or other 
abrasions, the cause will require removal. (See page 49.) 

Tar, liquor carbonis detergens, calomel, camphor, white precipitate, 
Friar's balsam, borax, chloral, corrosive sublimate, iodoform, naphthol, 
petroleum, bismuth, nitrate of silver, sulphur, tobacco, salicylic acid, 
alum, zinc carbonate, tannin, lead salts, acetic acid, etc., are exam- 
ples of drugs which have been found useful in local and general 
pruritus. 

Formulae for pruritus might be multiplied to the extent of the present 
volume. Enough has been given to show the principles upon which 
relief of the itching may be obtained. 

For local pruritus, especially of the anus and female genitals, the 
writer has discarded every drug save the unguentum conii. This very 
often acts like a charm. Sometimes he has added to it the fol- 
lowing : 

R • — Creasoti purif. HX xxx. 

Cocainse purif. gr. xij. 

Unguent, conii ^j. — M. 

At bed-time a small cold water should be given, after which the 
parts should be freely smeared over with hemlock ointment, some of it 
being pushed up in the vagina or rectum by the finger. This often 
speedily relieves even in diabetes. 

In obstinate cases of vulvar itching, a weak continuous current is of 
undoubtedly great value. (See under Anus, Pruritus of, page 49.) 

46 



714 PSOAS ABSCESS. 

PSEUDO - HYPERTROPHIC PARALYSIS — See Paralysis, 
Pseudo-Hyper trophic (page 587). 

PSOAS ABSCESS. 

Under Abscess the treatment of chronic varieties like the present 
has been already discussed. As a rule, Lister's method of treating 
psoas abscess upon the strictest antiseptic lines is the one which should 
invariably be adopted when the case comes before the surgeon prior 
to the discharge of the pus. There is no urgent reason, in the great 
majority of cases, for hasty action. The writer once was prevented 
making a free incision into a large psoas abscess which had already 
implicated the deeper layers of the skin. During the night the 
abscess burst into the bladder, and a rapid (almost immediate) re- 
covery resulted. 

Aspiration should be discarded, and a free incision should be made 
just above Poupart's ligament or in the loin. When the abscess is 
intra-abdominal the most rigid antiseptic precautions should be main- 
tained, and the abscess-cavity kept aseptic from the beginning to the 
end of the treatment ; and when this precaution is taken, a rapid 
healing up of the entire cavity may be fairly expected. In extra- 
abdominal cases the abscess should, be opened at the most dependent 
point. In all cases thorough drainage should be established by tubes 
under Listerine dressings. 

Where full antiseptic precautions are impossible or useless, or where 
the skin is already perforated, the opening may be enlarged, and the 
cavity washed out daily with some bland antiseptic solution, as boric 
acid. This is unnecessary in aseptic cases. 

Pitts lays great stress upon the necessity for loin drainage, and after 
opening the swelling in the groin by a small incision, he makes a large 
counter opening in the loin. He dwells upon the almost uniform suc- 
cess in dealing with psoas abscess, more particularly in children, which 
follows the carrying out of this method. 

The after treatment of these cases gives good scope to the physician, 
and the general lines for their management will be such as will be 
suitable for most scrofulous or debilitated patients recovering from 
exhausting diseases ; thus, diet is to be as generous and varied as the 
patient can partake of. Tonics, especially iodides, iron, and quinine, 
with cod-liver oil, abundance of fresh air, and removal to a bracing 
sea-side resort, with the exhibition of whatever special remedies, 
appear to be indicated in the case. 

As a rule, the patient should not be confined to bed, as the upright 
posture favors drainage, but rest in bed or suitable plaster or poro- 
plastic jackets will be indicated in cases depending upon disease of 
the vertebrae. In cases originating in caries or necrosis of the pelvic 
bones, the surgeon should attempt to remove all sequestra from the 
abscess, of course under strict antiseptic management. 



PSORIASIS. 715 

See under Abscess, page 14, for the methods of Wile, Bruns, Ver- 
neuil, and others. These have been successfully applied in a modified 
way to the treatment of the varieties of psoas abscess. Under Tuber- 
culosis will be noticed Lannelongue's plan of injecting solution of 
chloride of zinc into the tissues surrounding spinal and other abscesses. 

PSORIASIS. 

The constitutional treatment of psoriasis with our present knowledge 
is a simple matter, as in very many cases the patient appears to be in 
robust health, and there is no indication whatever for drugs beyond 
the presence of the eruption. It is true that sometimes anaemia is 
present, and hence the recommendation to give iron. Some authori- 
ties still regard psoriasis as evidence of a gouty or scrofulous diathesis, 
and recommend treatment accordingly, but, as a rule, such drugging, 
based as it is, upon a wrong hypothesis, only leads to disappointment 
and mischief. Diet should be such as will be best calculated to main- 
tain a perfect standard of health, and the fancy dietaries insisted upon 
by some specialists are as useless as they are irksome to the patient. 

Drugs which are supposed to have a specific action upon the disease 
when administered internally are : 

Arsenic. 

Phosphorus. 

Iodide of potassium. 

Chrysophanic acid. 

Turpentine and copaiba. 

Tar water and carbolic acid. 
Arsenic stands easily at the head of this list. It has so frequently 
been proved to be of the greatest service that it should be always 
selected in preference to any other drug, and only after it has been 
found to fail is the physician justified in resorting to other agents. 
It must be commenced in small doses, say 2 minims of Fowler's solu- 
tion, which should be steadily increased until 5, 7, or even 10 minims 
are given three or four times a day, diluted with water immediately 
after or along with food. The drug may be pushed until the physio- 
logical effects are noticed, and after redness or irritation of the con- 
junctiva the dose may be diminished or suspended for a short time, 
This treatment may be continued for a many months and should not 
be stopped upon the removal of the eruption. The Asiatic pills, each 
containing y 1 ^ grain, the liquor sodii arseniatis (1 : 100) or the liquor 
acidi arseniosi (1 : 100) in the same doses as Fowler's solution, may 
be given. One-twelfth grain of the arseniate of iron three or four 
times a day may be prescribed in the form of pill, Shoemaker reports 
success by giving the soda solution hypodermically, -^ to i grain of 
the salt, dissolved in water being injected daily into the deep cellular 
tissue of the back or buttocks. 

Phosphorus is believed by some to possess a specific effect upon the 



716 PSORIASIS. 

disease, and the writer has occasionally seen good effects follow its 
administration in doses of -^ grain in pill immediately after food. 

Iodide of potassium has recently been given in heroic doses (in 
ordinary quantities the writer has found it to fail always). Haslund 
gives very large doses, and Luisani has even exceeded these, and 
reports a rapid cure in a chronic case by commencing with 45 grains 
daily, and pushing the drug until 225 grains (nearly J ounce) were 
daily administered. The recent reports show that this drug is worth 
trying, but there is not yet data for an expression of opinion about its 
permanent value, though the immediate effects are striking. The limit 
of 100 grains daily need not be exceeded. Gutteling gives up to 2 
ounces of the drug daily. 

The iodide may be given in large doses, in combination with arsenic, 
and the writer has given the following : 

.&. — Potassii iodidi . ^ij. 

Liq. potassii arsenitis ^iv. 

Glycerini purif. . P . . . . . ^jss. 
Aquee camphorse ad ^viij. — M. 

S. — One dessertspoonful (2 drachms) to be taken after meals three times daily 
in a wineglassful of water. 

Each dose of the above will contain half a drachm of the iodide, 
and the total daily allowance will fall short of 100 grains. 

Chrysophanic acid or chrysarobin has been given internally with 
some success, but it often produces violent vomiting, diarrhoea, and 
griping, even in doses as small as i grain in pill. Nevertheless, the 
writer has seen benefit from it, and believes it worthy of a trial in 
those cases of psoriasis guttata where its external application is impracti- 
cable. Where it can be applied freely to large scaly patches be believes 
that its internal use is unnecessary. 

Kobert dwells upon the importance of selecting chrysarobin for 
internal use instead of chrysophanic acid. 

Copaiba, turpentine, antimony, colchicum, carbolic acid, creasote or 
tar, sulphur, alkalies, cantharides, and varions diuretics, purgatives, 
alteratives have been vaunted, but beyond correcting some temporary 
or accidental complication they cannot lay claim to any specific action. 

Cod-liver oil always does some good in the treatment of the affection 
in children, and in lean adult subjects it often appears to assist the 
action of arsenic or phosphorus. 

The local treatment of psoriasis is of more importance than the 
constitutional. Morris teaches that it is a local and not a constitu- 
tional affection, and every physician can recall examples of the disease 
successfully treated by agents locally applied. In practice it will be 
wise no matter what local applications are used to persist in the inter- 
nal use of arsenic at the same time. Warm baths and hot packs are 
of the greatest use in softening the scales before applying local agents, 
and in many instances they are essential. 



PSOKIASIS. 717 

Of all local remedies the writer still believes that chrysophanic acid 
or chrysarobin affords the best chances of success in the greatest num- 
ber of cases. The following extract from the fifth edition of his work 
on Materia Medica and Therapeutics, page 400, will convey his ex- 
perience and j udgment upon the value of the drug : 

" It is a 'remedy whose value in chronic psoriasis can hardly be ex- 
aggerated. An ointment of from J to 1 drachm, mixed intimately 
with 1 ounce of heated lard or vaseline, rubbed twice daily into the 
scaly patches of this disease, rapidly causes their disappearance. It 
frequently produces a painful erythematous inflammation of the sur- 
rounding healthy skin, which prevents its use by some patients. The 
writer after considerable experience of chrysarobin, is satisfied that 
this need never occur if the application be confined exclusively to the 
diseased islands, and not permitted to touch the healthy skin. This little 
point he believes to be the secret of the success of the treatment. Dr. 
Fox has advised application of chrysarobin made into a paste with 
water, smeared over the spots, and covered with collodion ; traumati- 
cine will be found even more satisfactory. 

" It acts both locally and constitutionally. Its local action may be 
seen by rubbing the ointment into the diseased spots on one side of 
the body of a patient affected with psoriasis. In a week or ten days 
the skin on the side so treated shows decided signs of improvement not 
in the least apparent on the opposite, and as the diseased patches 
begin to disappear under the direct application of the remedy, those 
regions to which it has not been applied eventually begin to show 
signs of improvement also ; and the writer found by persistently con- 
tinuing the application to the spots originally so treated, the entire 
surface of the body cleared up. This is probably caused by its ab- 
sorption into the system and its conveyance to all the diseased areas. 
The experiment is not an easy one, however, owing to the difficulty of 
preventing the ointment being diffused over the entire cutaneous sur- 
face, and the application cannot be too long continued, because an 
ointment which causes no irritation whatever for a few weeks, so long 
as the spot to which it is applied remains scaly and diseased, soon 
acts as a powerful irritant to the same spot as it becomes resolved and 
healthy. 

"This observation is strengthened by the experiments performed by 
Lewin and Rosenthal upon rabbits. They found that an ointment of 
chrysarobin, when applied externally, was absorbed and partly con- 
verted into chrysophanic acid in the system. A part not oxidized was 
demonstrated in the urine. 

" The deep purplish discolorations which it produces on the skin and 
bed-linen are barriers to its use, and great care must be exercised in 
applying the ointment to the face, as it causes oedema of the eyelids, 
with discoloration, though it can be applied to the scalp (15 grains to 
1 ounce) with benefit. 

" Brooke's salve sticks are a splendid way to use chrysarobin. Lie- 



718 PSORIASIS. 

bermann finding that chrysarobin had such powerful affinity for oxygen, 
thought that its action depended upon this, and that in its oxidation 
to chrysophanic acid it robbed the parasites of their oxygen and killed 
them. He has discovered an almost identical substance, which he now 
uses instead of chrysophanic acid." 

This is anthrarobin, which has been successfully employed in several 
cases as a 10 per cent, ointment, which may be applied to the face and 
eyelids, though it leaves a yellow stain. It is safer than pyrogallic 
acid. It may also be painted on as a 15 per cent, tincture, after scrub- 
bing with soap and water to remove the scales. 

The writer has obtained the best results by painting the affected 
patches with a paste of the acid made by rubbing it up with water or 
spirit, and over this applying a piece of rubber adhesive plaster. In 
using the salve sticks the greased spot may be similarly covered over. 
By these means several points are gained: 1. Only the diseased patch 
is subjected to the action of the drug, the healthy skin being un- 
touched. 2. More concentrated preparations can be applied. 3. The 
action of the drug upon the diseased spot is continuous. 4. No soil- 
ing of linen or bedclothes or discoloration of the face occurs. Unna 
and Stelwagon use the acid in the form of medicated plasters. These 
are very valuable for large patches. 

Of the most recent methods of employing chrysophanic acid or 
chrysarobin locally, the most elegant and efficacious is the glycerinum 
saponatum mentioned on page 231. Hans Hebra adds 10 per cent, of 
chrysarobin to the 92 per cent, mixture ; this is known as his chrysa- 
robin glycerinum saponatum. 

Tar is the local remedy which has still the highest place in the 
treatment of psoriasis, among the majority of skin therapeutists; and 
with many skilful physicians the following epitome of the treatment 
of the disease would be endorsed : Give arsenic internally ; remove 
the scales by bathing, packing, or scrubbing ; rub in the ointment of 
tar, and make the patient sleep in his tarry underclothing. 

The tar treatment may be carried out in many ways. The liquor 
carbonis detergens may be made into a less objectionable ointment 
than the official unguentum picis liquidse. Two drachms to 1 ounce 
of lanoline may be used, or it may be mixed with spirit lotion, 1 : 10, 
which can be applied upon lint and covered with oiled silk or thin 
mackintosh ; or the liquor may be brushed in its full strength over the 
spot and be allowed to dry. 

Oil of cade or juniper tar, is a more agreeable preparation than 
the pix liquida obtained from the pinus sylvestris. It may be mixed 
with oil or used as an ointment (1 to 4 of spermaceti ointment), or the 
following excellent application may be used : 

K.-Oleicadinij Equal parts. -M. 

Cerse flavse > 
Make an ointment with the aid of heat. 



PSOKIASIS. 719 

Vidal makes the oil of cade into a soap with an equal quantity of 
glycerole of starch and 5 per cent, of soft soap. This is rubbed in 
every evening and washed off in the morning. 

Various other tarry preparations are in use, and Hutchinson com- 
bines the tar and chrysophanic acid plans in an ointment containing 
10 graius of white precipitate, 10 grains of the acid, and 10 minims of 
liquor carbonis to 1 ounce of benzoated lard. This is perhaps the best 
of all tarry applications in psoriasis. 

Hot baths, which are so valuable in the treatment of psoriasis, are 
an essential part of a successful tar cure. The patient should lie in a 
large warm both for 30 to 60 minutes, during which time he may apply 
gentle friction by a piece of soft flannel or by a soft brush to the scaly 
patches until the epithelial products are removed. The addition of an 
alkali like the bicarbonate of sodium or potassium, to the extent of about 
4 ounces to a moderate sized bath, is a great advantage. After coming 
out of the bath and getting dried he should roll himself up in a blanket 
until the cuticle loses its retained moisture, after which any of the tarry 
preparations just mentioned may be freely rubbed in. 

Some authorities, as Hebra and Kaposi, advise the application of 
green soap daily until the scales are removed and a raw oozing base 
becomes visible. The spiritous solution of the soap may be rubbed 
in with strong friction, or the patches may be scrubbed with soap and 
water by the aid of a brush. Ellinger employs sand to remove the 
scales. 

The writer has never seen any benefit follow these painful measures. 
When he wishes to get the scaly patches cleansed he resorts to the 
warm alkaline bath and local wet packs. Large patches soon yield to 
a pad of lint soaked in water or a weak alkaline lotion, covered by 
oiled silk, and kept continually in its place by comfortable bandaging. 

After such preparatory treatment the action of local remedies is 
much more rapid and satisfactory, and some physicians content them- 
selves with these ablutory measures, and the internal use of arsenic, 
assisted by diuretics or diaphoretics. Where baths are not obtainable, 
Jamieson recommends that an ointment, consisting of 10 parts of car- 
bonate of ammonia, 25 of lanoline, and 50 of cold cream, be applied 
daily to remove the scales, which it most effectually does. 

Creolin (5 parts), vaseline (100 parts) ; thymol (1 part), lard (20 
parts) ; naphthizin (1 part), lard (8 parts) ; creasote (1 part), lard (8 
parts), ichthyol (50 parts), vaseline (100 parts); beta naphthal (1 
part), lard (9 parts) ; pyrogallic acid (5 to 10 parts), lard (100 parts) ; 
and for extensive surfaces Besnier uses the following paint: 

R .-Acid, pyrogallic j u ft 

Acid, salicylic i 
JEtker. et spt. vini rect. q. s. 
Mix and add 

Collodii fiexil. « 5 iiss. — M« 



720 PSOEIASIS. 

Pyrogallic acid is, undoubtedly, very efficacious ; but its use appears 
to be not without danger, as two fatal cases are reported. Jarisch used 
an ointment of 1 drachm to the ounce, but a much weaker preparation 
may be used with great safety ; 15 to 20 grains per ounce is perfectly 
safe and unirritating, but it should not be applied to the entire body, 
as its absorption may give rise to alarming fever, strangury, and 
melsena. It stains black or dark brown, but weak ointments may be 
safely applied to the head and face. 

Vleminckx's solution (pentasulphide of calcium) is applied by rub- 
bing or dabbing it into the affected patches with a strong brush or 
flannel until the skin bleeds, after which it is washed Off, and cold 
cream or lanolin applied. 

Shoemaker gives the following formula of Wilkinson's ointment, as 
modified by Hebra : 

B . — Sulplmris sublimat. \ - - z 

Olei cadini i 

Saponis viridis \ _ . 2 . 

Adipis prsep. > 
Cretae praep 3 ijss. — M. 

Hebra also used the following mixture, which is a very valuable ap- 
plication in chronic cases with large isolated scaly patches : 



R . — Picis liquidee 

Spt. vini rectif. }- aa ^j. — M. 

Saponis viridis 



}- 



Mercurial preparations are used, and upon the bacterial theory there 
has been a revival of the treatment by weak ointments of bichloride 
(1 : 50), biniodide (1 : 50 to 1 : 100), ammoniated (1 : 15). Nitrate, as 
citrine ointment and the oleate (10 to 20 per cent.), have been recently 
advocated. 

Rochard's ointment consists of: 

R . — Hydrarg. chlor. mitis 5 ss. 

Iodi purif. gr. xj. 

Unguent, simplicis ...... 3 xiv. — M. 

Shoemaker, in hospital practice, uses the following : 

R .—Unguent, hydrarg. nitratis j .... ^ ^ _ gij.—M. 

Unguent, picis liquidse i 

In private practice he recommends an ointment made by diluting 
the officinal ointment of the nitrate or oleate of mercury with one-half 
or two-thirds of lard or butter, adding half to one drachm of either 
naphthol or chrysarobin to each ounce. 

Turpentine, iodide of sulphur, iodide of lead, and pure iodine have 
been also used. 



PTYALISM. 721 

There is not yet sufficient data to enable one to arrive at a conclu- 
sion regarding the values of hydrochlorate of hydroxylamine, hydro- 
chlorate of hydrazine, or hydrazine salicylic acid, or of aristol — the 
new thymol derivative. 

Above are the most frequently employed combinations, though for- 
mulae might be given without end, each specialist having his favorite 
combinations. In the treatment of a diseased condition like psoriasis, 
which varies little in its characters, and cannot be well said to have 
"stages" in its progress, as is the case with eczema, the great mistake 
which the student is sure to make is to begin with a local application, 
and before it has had time to act change it for another, and so on all 
through the progress of the disease. Selecting either the tar or chry- 
sophanic acid, it will be much better to stick to it all through in every 
case until experience proves that it is not going to give satisfactory 
results. Life is too short to attempt to gain an experience of the result 
of every special application, and it requires years of patient watching 
and observation in order to thoroughly master all the little minutiae 
required in the successful use of any one of the above remedies. 

Electricity used either as the constant, interrupted, or static current 
has been reported as giving good results in several cases when locally 
applied, and it need not interfere with any of the above applications. 

PTYALISM. • 

Increased flow of saliva is but a symptom of various affections, and 
its treatment will depend upon the cause which, when diligently sought 
out, is to be met by appropriate remedies. Thus, various local, tongue, 
or mouth affections, as delayed dentition or aphthous stomatitis in 
children and secondary syphilitic affections in adults, may cause the 
salivation, which will be readily checked by treating the primary cause. 

When ptyalism is caused by the administration of a mercurial, it 
should be instantly stopped in the great majority of cases, for, as 
already pointed out, it will be seldom necessary to cause salivation 
during the treatment of syphilis or any other affection by mercury. 
With the suspension of the drug the increased flow of sajiva, as a rule, 
speedily subsides, but sometimes profuse salivation of a degree difficult 
to control may be met with where mercurials have been administered 
by quacks. The best local application will be chlorate of potassium 
(1 : 40), which should be used as a mouth-wash every hour, after first 
cleansing the buccal cavity with a weak solution of the permanganate 
of potassium. Before and during a course of mercury the greatest 
attention should be paid to the state of the gums and teeth in order to 
prevent ptyalism. This is most carefully attended to at Aix and is 
one of the details upon which the great success of the treatment there 
depends. 

When in ptyalism from excessive mercurialism the gums become 
much swollen and ulceration has occurred, astringents will be required. 



722 PUERPERAL CONVULSIONS. 

Alum (1 : 40), chloride of zinc (2 grains to 1 ounce), tannic acid (1 : 40), 
decoction of oak bark, or other vegetable astringents may be used. The 
overwhelming fetor may be met by weak solutions of chlorinated lime 
or soda, or by a mouth-wash consisting of carbolic lotion (1 : 80) or 
iodine (J of tincture in 40). 

The glycerin of borax is a most efficient local application, but it 
must be used almost continuously. 

Internally the chlorate of potassium may be given with advantage, 
and if combined with a mineral acid or iron preparation containing a 
free acid a better effect will be obtained. 

Stimulants may be needed in bad cases, and only liquid food can be 
swallowed. 

When ptyalism is the result of some reflex action, the amount of 
saliva can be easily diminished by the internal administration of 
atropine, belladonna, hyoscine, or opium in small doses, given until 
dryness of the throat occurs. It is, as a rule, not advisable to give 
atropine in cases like mercurial salivation, or where ptyalism has been 
produced by iodine or other drug. In these instances the increased 
salivary flow is probably caused by an attempt on the part of nature 
to cause the elimination of the poison. The writer, acting upon this 
theory, has utilized the powerfully stimulating action of pellitory root 
upon the salivary glands in order to encourage the flow of saliva. 
Several quarts of the secretion may be caused to flow away in this 
manner, but where the gums are swollen and ulcerated this plan 
should not be adopted. 

Iodide of potassium has been given in mercurialism with some bene- 
fit, but it is a questionable experiment to try it, as it may greatly 
aggravate the aftection. 

Bromide of potassium has proved useful in the salivation of preg- 
nancy. It may be combined with small doses of belladonna or 
hyoscyamus. 

PUERPERAL CONVULSIONS. 

There must ever remain differences of opinion regarding the best 
treatment of any affection until its pathology is cleared up ; and in 
the present state of our knowledge there are widely diverging view 7 s 
upon the pathology of eclampsia occurring in connection with the later 
months of pregnancy. The treatment which is based upon the theory 
that the disease or condition is a purely functional affection, or as re- 
garded by Santos, merely an " acute peripheral epilepsy," is as highly 
efficacious and as reliable as the treatment based upon the theory that 
the eclampsia " depends upon ursemic poisoning due to an inadequate 
secretory activity of the kidneys," as maintained by Spiegelberg. 
Hence, forgetting all theories upon the subject, the physician is justi- 
fied in adhering to the remedies which a wide and extensive experience 
has proved to be most valuable. 



PUERPERAL CONVULSIONS. 723 

Prophylactic treatment is of importance, and experience has shown 
that in those cases of pregnant women who exhibit large amounts of 
albumin in the urine, attention to the conditions of the kidneys is likely 
to materially diminish the tendency to eclampsia. The skin, bowels, 
and kidneys should be made to work with activity and efficiency, as 
already detailed in speaking of the treatment of Bright's disease. 

One of the most powerful prophylactic measures is a diet consisting 
exclusively of skim milk. This diet might be supposed to act equally 
well whether the eclampsia was the result of an epilepsy or of urasmia, 
since it is one of the best remedies in either diseases when unassociated 
with the puerperal state. Auvard recommends the milk diet strongly, 
and Blanc advises full doses of chloral as a prophylactic where there 
is much albumin. 

The question of inducing labor, or hastening delivery, if labor has 
already commenced, will have to be discussed. During pregnancy it 
may be laid down that interference in this direction is seldom needed, 
and as Spiegelberg points out : 1. The convulsions may subside with- 
out interrupting pregnancy. 2. If severe, labor will set in sua sponte. 
3. All the mild proceedings which would suffice for provoking pains 
are too slow in their action, while those that operate more rapidly irri- 
tate the uterus too greatly, forced delivery being forbidden under these 
circumstances. 

When labor has already commenced, or is about commencing, there 
need not be any hesitancy about hastening it ; in severe cases this must 
be carried out with rapidity and firmness, the expectant plan of treat- 
ment being then abandoned. The steps to be taken will depend upon 
the stage of the labor already present, and the condition of the os and 
cervix. 

As a rule, rupture of the membranes will be the best procedure, 
after which mechanical dilatation of the os with the fingers, and in 
rare cases, where the convulsions are very severe, the os may be incised. 
Where, notwithstanding, the puncture of membranes and dilatation of 
the os or cervix, labor does not proceed as quickly as the urgency of 
the symptoms would render necessary, delivery must be accomplished 
by version or the forceps, and the placenta should be taken away 
without undue waiting, but anything like precipitancy should be 
avoided. 

Though the induction or hastening of labor has been mentioned at 
the beginning of the remarks upon treatment, it is not to be understood 
that it is the first thing to be achieved, or that other remedies are to 
be withheld until it is accomplished. Upon the contrary, these are to 
be rapidly pressed into the service before the rupture of the membranes 
is performed, or during the period that the dilatation of the os is being 
accomplished. 

Blood-letting is undoubtedly cf the most unquestionable utility, the 
rapid reduction in the blood pressure which follows having a very 
marked effect upon the frequency and severity of the convulsions, but 



724 PUERPERAL CONVULSIONS. 

as the disuse of blood-letting has at the present time caused the opera- 
tion, which at one time was considered a very trivial one, to be re- 
garded in a serious light by most practitioners of the present day, the 
majority of whom have never seen it performed, it is seldom done for 
puerperal eclampsia. Other measures equally efficacious are, however, 
available. 

Chloroform inhalation, to the extent of producing deep narcosis, is 
an agent of great value in eclampsia; and statistics show excellent 
results since the introduction of this method of treatment. Ether, 
or other anaesthetic, may be tried where chloroform is not available. 

Next in value to the chloroform treatment is that by chloral, which 
should be pressed in large doses when the patient is able to swallow 
between the attacks, or it may be given by the rectum in all cases with 
advantage, either alone or in combination with the bromide of potas- 
sium — 20 grains of chloral and 40 of bromide being injected every three 
or four hours in severe cases. 

The best practice is to give chloroform by inhalation, and to keep 
up the effect by chloral and bromides per rectum. If this be done cau- 
tiously, the chloroform can be suspended until the immediate premoni- 
tory symptoms or signs of a convulsion are experienced, when the 
chloroform sponge may be immediately placed over the patient's mouth 
and nose. 

WinckePs results from this combined chloroform and chloral method 
of treatment amounted to a death-rate of only 7.6 per cent. 

Where the symptoms do not readily yield to these remedies, especi- 
ally in very plethoric subjects, the physician should not hesitate to open 
a vein in the arm by a free incision, and let out 15 to 20 ounces of 
blood. After blood-letting, should the convulsions return, chloroform 
must be very cautiously given, if at all, and unless they are very 
severe, it will be well to suspend both the chloroform and chloral, and 
trust to enemata of bromide of potassium (1 to 2 drachms) and hypo- 
dermic injections of morphine. Some authorities always combine mor- 
phine with the chloral treatment, and give nothing else, but it is very 
probable that this method will not give as good results as the chloro- 
form and chloral plan. In some cases all these remedies have been 
successfully employed when the convulsions have been very for- 
midable. 

Trousseau's method of compressing the carotids often stops, or very 
materially modifies the attack, and though not to be entirely depended 
upon, it may be advantageously employed in most cases to gain time 
until the chloroform narcosis is established. 

While the above measures are being used, and labor is being has- 
tened, the physician should not omit to stimulate the excretory organs, 
and the ordinary treatment so successful in dealing with uraemia may 
be safely pushed after delivery has been accomplished. As already 
detailed, this is based upon the lines of causing rapid elimination of the 
retained excrementitious products, as urea, leucin, tyrosin, etc. 



PUERPERAL FEVER. 725 

Purgatives of the saline class, the best of which is the sulphate of 
magnesia, or compound jalap powder, are to be freely given. Elaterin 
or elaterium has so often failed in the writer's hands in critical cases 
that he prefers to trust the ordinary salines. 

The skin must be acted upon powerfully. The best of all means for 
this purpose in puerperal eclampsia is the free use of the wet pack. 

Pilocarpine has been so frequently found to cause oedema of the lung 
that Jaggard, Phillips, Spiegelberg, and others wisely caution the pro- 
fession about its serious dangers. The writer prefers nitrite of amyl or 
nitro-glycerin where a rapid effect is necessary. Ordinary diuretics are 
not to be depended upon. Large doses of caffeine have, however, been 
very beneficial. 

The writer has chanced to meet with puerperal convulsions in several 
cases after delivery had been accomplished in the normal manner, and 
in these eliminatory treatment was most satisfactory, free purgation by 
sulphate of magnesia and jalap powder, with the hot mustard pack or 
mustard blanket bath, acting rapidly and effectually. 

Blanc's discovery of a microorganism — a slender bacillus — in the 
urine of patients affected with puerperal eclampsia would point to the 
importance of eliminatory measures. 

In desperate cases, the best treatment will, in the opinion of the 
writer, be that suggested by Bozzolo for uraemia, and mentioned upon 
page 75. It will consist in the removal of a fair quantity of blood by 
opening a vein in the arm, after which weak saline solution may be 
injected subcutaneously or into a vein, with the view of diluting the 
remaining blood left in the body. (See, also, under Anaemia, upon 
page 38, for the details of the methods of injecting salines.) 

PUERPE RAL FEVER. 

In the treatment of this formidable affection, prophylactic measures 
are of primary importance. These may be summed up in two words 
— absolute cleanliness. The patient, her house, bed linen, and sur- 
roundings should be as clean as possible. The hands, dress, and instru- 
ments of the accoucheur and of the nurse must be placed beyond the 
possibility of conveying microorganisms. Antiseptics are of vital im- 
portance, but the accoucheur should not be led into the error of relying 
upon them solely. Cleanliness of the most scrupulous degree is all 
that is necessary. When this has been achieved in every detail, anti- 
septics or disinfectants may then be used to render " assurance doubly 
sure." 

In order to carry out this system, a rigid examination of the patient's 
surroundings should be made. There is little use in the scrupulous 
cleanliness of the attendants if the lying-in room should chance to be in 
direct communication with a sewer, or if friends and visitors are pro- 
miscuously admitted to her chamber laden with the germs of puerperal 
fever, erysipelas, or scarlatina. 



726 PUERPERAL FEVER. 

Dr. Byers, in a valuable paper appearing in the Dublin Monthly 
Journal, May, 1891, proves by recent statistics the great importance of 
making as few vaginal examinations as possible, and of using as a pro- 
phylactic dilute sublimate solution. 

The irrigation of the vagina during labor, especially after vaginal 
examination, is of great importance, and the examinations should be as 
few as possible. After careful cleansing of the hands and arms of the 
attendant by soap and water, they may be rinsed in a weak carbolic 
lotion (1 : 50), or in a dilute solution of the permanganate of potassium. 
Either of these may be used as a vaginal douche. 

Bichloride of mercury — the most powerful germ destroyer — has been 
very much used of late years, a solution of 1 : 1000 being employed as 
an antiseptic solution for the hands and instruments. The serious 
mishaps which have been known to follow its routine use, especially as 
a vaginal or uterine douche, have led to its now being much less fre- 
quently selected. 

The vagina should be invariably irrigated after delivery, and Speigel- 
berg lays down the rule that if the hand had been introduced into the 
uterus its cavity should be well washed out. 

Though it is not generally considered necessary in Germany, where 
antiseptic midwifery is the rule, to daily wash was out the vagina after 
labor with antiseptics unless where there are considered to be special 
reasons, the writer invariably follows the practice of having the canal 
irrigated twice a day for the first fortnight, and as he has never had a 
case of puerperal fever occurring during the last sixteen years ; he 
thinks it possible that it may be owing to this precation. There is no 
danger or drawback to the practice if carried out by a skilled nurse, 
provided that weak permanganate solution, about 1 ounce of Condy's 
fluid to a quart of tepid water, be used, and if the vagina pipe be not 
passed up into the uterus. Sometimes severe pain and shock follow 
the injection of fluids into the uterus when there is no outlet for the 
flow, and when undue pressure is maintained. The practice of securing 
the expulsion of all clots from the uterine cavity after labor by pro- 
longed kneading, and the administration of ergot are universally recog- 
nized as valuable prophylactic measures. 

When symptoms of septic poisoning actually occur as evidenced by 
pyrexia, rigors, etc., the vaginal irrigations, if not already in use, should 
be commenced. A 2 per cent, solution of carbolic acid may now be 
used, and under special circumstances double this strength may be 
safely employed. Every eight hours the vagina may be washed out 
by the nurse, and once a day the physician should pass a tube up into 
the uterus, and thoroughly cleanse its cavity under a low pressure, and 
taking care not to introduce air. Schiicking carries out a system of 
permanent irrigation. Deipser disregards all ordinary antiseptics, and 
relies upon a stream of hot water (122° F.) for six days after delivery. 
The Russian method of constant irrigation of the vagina by a stream 
of hot carbolic lotion (120° F.) has been reported as giving excellent 



PUERPERAL FEVER. 727 

results. The apparatus of Morosow is used. The Italian practice is 
to co)it!)iuouth/ irrigate the uterus by a stream of carbolic solution by 
means of a Breus-Bozernan-Fritsch tube or Kurz catheter, the fljw 
being kept up for hours until the temperature falls. 

In this country the accoucheur has generally been satisfied to use the 
uterine douche once a day for the first four or five days after pyrexia 
appears - substituting in some cases for the carbolic a lotion of bichlor- 
ide of mercury 1 : 4000. The douche tin with rubber tubing should 
be preferred to the ordinary Higginson's syringe. 

When, notwithstanding the thorough disinfection of the uterus and 
vagina, the deepening of the symptoms show that the virus has reached 
the general blood stream, other measures must be adopted. 

Fever will claim attention. When this is moderate and the symptoms 
only indicate a minor degree of septic poisoning ordinary diaphoretics 
are indicated, but when a persistent high temperature is recorded, qui- 
nine in large doses is indicated. Ten grains may be given every four 
or six hours until the full physiological effects of the drug are produced, 
or a dose of 30 grains may be given at once. 

Antipyrine and antifebrin have both given excellent results as far as 
reduction of temperature is concerned, and where quinine fails and the 
method next to be mentioned is not feasible, they may be used with 
great advantage. It would appear that though the new antipyretics 
have forced quinine almost out of use in every other severe pyrexial 
conditien, in the treatment of puerperal fever it has still maintained its 
supremacy, notwithstanding that it often fails even in 20 or 30 grain 
doses to affect the temperature. In cases where it thus fails in reduc- 
ing fever heat it is felt nevertheless to have done good as a tonic and 
stimulant, and hence its popularity in a disease characterized by pro- 
found prostration, and often associated with grave cardiac weakness. 

In severe hyperpyrexia quinine is useless. Even the certainty and 
rapidity of the new antipyretics are not to be depended upon, and the 
patient will speedily sink unless the fever heat, which is incompatible 
with life, be soon subdued by the only reliable agent — cold water. 
This may be used as the cold wet pack, in which the patient's entire 
body is submitted to the action of water at 60° F. or lower by being 
enveloped in a wet sheet. If the physician pours cold water continually 
over the wet sheet all the advantages of a cold bath are obtained, but 
there is no doubt that to plunge the patient into a cold bath, or tepid 
bath afterward gradually cooled down by the addition af cold water, 
is the most rapid and efficient antipyretic treatment that can be devised. 
Even in puerperal fever, life may be saved by its means. The duration 
and frequency of the bath or pack will depend upon the height of the tem- 
perature and the influence which it exerts upon its reduction, and also 
upon the symptoms exhibited by the patient, the general management 
of the remedy differing in no way from its use in the ordinary continued 
fevers. 

Alcohol alone, or in conjunction with the bath or other antipyretics, 



728 PUERPERAL FEVER. 

is of the greatest value, but it must be given with no sparing hand 
where the symptoms of cardiac failure and general exhaustion call for 
its employment. The writer believes that most satisfactory results will 
be obtained from 5 grain doses of antipyrine every two hours, alter- 
nately with 4 to 8 drachm doses of whiskey — that is, one or other 
remedy being given each hour in milk or strong beef tea. 

Blood-letting is practically out of the question. 

Purgatives have been employed in the early stages where there is 
no evidence of peritoneal mischief, and their antipyretic action is 
sometimes well marked ; 5 grains of calomel may be given, followed 
by 4 or 6 drachms of Kochelle salt. 

Warburg's tincture has succeeded in the reduction of fever heat and 
all its attendant evils when every other remedy has been known to 
fail. It can be used in collapse when other antipyretics are contra- 
indicated. Half an ounce may be administered at one dose, and this 
may be repeated in three hours again. 

Tinctures of digitalis, veretrum viride, and aconite have been recom- 
mended, but the results do not warrant their use in a disease where 
collapse and cardiac failure are often prominent features. Even digi- 
talis as an antipyretic is useless, except in doses which may seriously 
tell upon the cardiac muscle. 

Salicylic acid, the purified salicylate of sodium (of Charteris), and 
the tincture of eucalyptus globulus are safe, reliable, and agreeable 
antipyretics, which can be used when quinine and antipyrine disagree. 

Turpentine has long enjoyed a reputation in the treatment of puer- 
peral fever, and it may be tried with some hope of success in conjunc- 
tion with the measures already mentioned. The form of capsule is 
the most agreeable and efficient, and 15 minims may be given every 
four or six hours. It may also be given by inhalation, the air of the 
patient's apartment being saturated with it by pouring the spirit of 
turpentine upon the surface of hot water. It may be advantageously 
given in the form of enema when there is much tympanitis, and in the 
form of a stupe or fomentation. It is an efficient and agreeable coun- 
ter irritant when applied to the tense abdomen. 

Beyond the treatment of symptoms as they arise, and the reduction 
of fever heat when this threatens life, little can be done after the 
onset of symptoms which prove that the case is one of true puerperal 
fever, save to employ every possible means whereby the patient's 
strength can be kept up by the most sustaining liquid dietary. 

Special symptoms must be met by appropriate remedies. Pain is to 
be combated by opium in full quantities, the amount and persistency 
of the pain being the guide to the doses. Pain, as in peritonitis or 
pleuritis, may be relieved by poulticing or by hot fomentations, by 
cold compresses, or by hypodermic injections of morphine near to the 
seat of the suffering. 

In the peritoneal form of puerperal fever the treatment will be the 
same as for the general condition, plus such local anodyde measures as 



PUERPERAL MANIA. 729 

the symptoms indicate. Vomiting must be controlled by ice and 
rectal feeding. Leeching is recommended in these cases, but the result 
is very questionable in a disease where every drop of blood which the 
patient possesses is required in the struggle against the septic organ- 
isms. The same remarks apply to calomel and the inunction of mer- 
curial preparations. 

These remarks do not apply to cases of pure puerperal peritonitis, 
where the constitutional disturbance appears to be only secondary to 
the localized peritoneal inflammation. In such cases the remedies 
useful in puerperal fever may be administered, as quinine, alcohol, 
opium in large and frequently repeated doses, cold compresses, or Leiter's 
tubes, or hot poultices, leeches, calomel, and other remedies indicated 
in peritonitis (which see, page 607). 

The question of opening the abdomen and washing out the perito- 
neal cavity has been solved by experience both in true puerperal 
fever, with peritoneal complications, and in true puerperal peritonitis, 
and little encouragement can be obtained from a perusal of the re- 
ported results. To be of any use in puerparal fever the operation 
must be done at such an early stage as would cause most men to hesi- 
tate recommending it. In those cases where there is a clear diagnosis 
of an inflammatory attack, confined to the pelvis or abdomen, without 
the constitutional element of general infection, an operation may not 
only be advisable, under certain circumstances, but it may be the only 
means whereby life can be saved. 

PUERPERAL MANIA 

The prognosis being so good, the duration of the attack being gen- 
erally so short, and the chance that in some cases sudden and rapid 
restoration to sanity occurs, all lead the physician to advise the trial 
of home treatment before resorting to an asylum. 

The most easily managed cases, as a rule, are those occurring soon 
after labor, and such may fairly be expected to recover within two or 
three months, or less. Obstinate cases must ultimately be sent to spe- 
cial institutions possessing every administrative machinery for coping 
with all difficulties in carrying out moral treatment. The first ques- 
tion which may crop up will be the one of suckling. As a rule, the 
mother should not be permitted to nurse her child. In rare cases this 
may appear so simple and easy that the patient's relatives may insist 
upon it, but the physician should warn them that dangerous impulses 
may suddenly seize the patient at any moment, and that she should 
not be trusted with the custody of the infant for a moment, nor should 
she be allowed to remain alone under any circumstances. 

Every possible source of excitement should be avoided, though it is 
very doubtful if the old method of confining the patient to her bed 
in a darkened room should be followed. Firmness, stillness, and per- 
fect rest, are to be maintained, and the infant should be removed 
from the room as soon as the patient appears not to be excited by its 

47 



730 PUERPERAL MANIA. 

removal, and, as a rale, it should be kept entirely away from her 
until recovery is established, or until she expresses a desire to see it 
again. One or more good nurses are essential, and the friends should 
leave the case entirely in their hands under the supervision of the 
medical attendant. 

The ordinary functions must be closely seen to, the bowels, bladder, 
and stomach being watched, and any indigestion or vomiting, consti- 
pation, or retention of urine, should be remedied. The diet should be 
generous, but light, as much milk, good soup, or other liquid nourish- 
ment as the patient can be caused to swallow being administered at 
short and regular intervals. Forced and rectal feeding may be neces- 
sary. Sleep must be procured, but opium, morphine and chloral are 
to be avoided. The drug is sulphonal in full doses in such cases, and 
30 grains may be given at bed-time, and repeated in six or eight 
hours. It may be sprinkled between two slices of bread and butter, 
or given between the layers of a jam sandwich, or, where a quicker 
effect is desired, it may be dissolved in boiling water, and swallowed 
hot. 

Ice or cold compresses to the forehead, with a sinapism at the back 
of the neck, assist the action of the hypnotic. Leeching of the temples 
and other debilitating measures are to be condemned. 

Alcoholic stimulants are, as a rule, to be avoided, but in weak and 
anaemic subjects, especially those who have had much hemorrhage 
during or after labor, a good, sound claret may be given with food in 
liberal quantities. Should any increase of excitement be noticeable 
after alcohol it should not be repeated, but a tonic containing quinine, 
combined with small quantities of digitalis, may be substituted for it. 

Bromides are most valuable in the treatment of the chronic stages 
where acute exacerbations of excitement occur, and iron in some form 
or other is generally indicated before the patient's restoration to health. 
It is needless to say that the condition of the vagina, uterus, and ovaries 
should receive the closest scrutiny, and any departure from health 
should be remedied, but the practice of making frequent vaginal 
examinations is to be strongly censured. 

In mania or insanity following prolonged lactation, the weaning of 
the child should not be delayed, and the chief indications will be a. 
liberal and highly nutritious diet, with free alcoholic stimulants, espe- 
cially good ale, porter, or stout, and judicious moral treatment. The 
condition of the uterus will demand attention, and as subinvolution 
will often be found in connection with anaemia, both general and 
cerebral, the indications will be for iron in large amounts, with quinine 
and ergotine, as in the following pill : 

R. — Ext. ergotae gr.j. 

Ferri reducti , . gr. iij. 

Quininse sulph. . gr. ij. — M. 

Make 36 of these pills. 
S. — One pill to be taken after meals three times a day, and at bed-time. 



PURPUKA. 731 

PUERPERAL PERITONITIS— See under Puerperal Fever (at 
page 729)'. 

PURPURA. 

In mild cases of simple purpura the patient may be allowed to move 
about. His diet should be mixed and very generous, and he should 
have a mixture like the following : 

K . — Liq. potass, arsenit 3 ss. 

Tinct. ferri chlor 3 iijss. 

Glycerini ^j. 

Aquae camph ad ^viij. — M. 

S. — One tablespoonful to be taken three times a day in water, after meals. 

As a rule, the use of the above will be speedily followed by improve- 
ment. In severe cases of so called simple purpura, rest in bed is 
essential, and large doses of iron are still believed to be the best 
remedy ; but in all serious cases and in purpura hemorrhagica iron 
is not to be relied upon, except in the anaemic stage following large 
hemorrhages. 

W. B. Richardson, who describes an " aqueous " variety of purpura 
hemorrhagica, treats it with fresh animal food, diminished amount 
of fluids, and frequent purgation, giving, at the same time, a mixture 
containing superphosphate of iron combined with peroxide of hydrogen. 
In the " scorbutic " variety he advises the same treatment as is indi- 
cated in scurvy, and in the vascular variety he relies upon turpentine. 

Where hemorrhages from mucous surfaces are present the case must 
be regarded as serious, and absolute rest in bed insisted upon. The 
air of the patient's apartment must be saturated with the vapor of 
turpentine, which is also to be given in the form of capsule, and when 
the hemorrhage amounts to any quantity ergot must be given freely. 
The hypodermic injection of 1 or 2 grains of extract of ergot may be 
resorted to several times daily. The room should be kept very cool, 
excess of bedclothing must be avoided. The diet should consist of 
cold milk and cold beef jellies ; constipation and purging are both to 
be equally avoided. Stimulants are to be given with caution. 

According to Muskett, Eustace Smith recommends the follow- 
ing draught every morning or every second morning to a child six 
years old : 

K. — Olei terebinthinse ^ij. 

Olei ricini ^ij. 

Mucilag. tragacanth. ...... 311] . 

Syr. limonis gss. 

Aqu?e menthse pip. . . . '. . . .ad ^j. — M. 
S. — To be taken in the morning. 



732 PYEMIA. 

Where the hemorrhage continues after the use of this draught, he 
gives a mixture containing 3 or 4 minims of Fowler's solution and 15 
minims of tincture of iron, three times a day, freely diluted with water, 
after meals, to a child of the same age. 

Where ergot fails in controlling hemorrhage, other agents may be 
employed, as acetate of lead, alum, tannic or gallic acids, tincture of 
larch, sulphuric acid, or hazeline, and any of the remedies mentioned 
under hemorrhage. Ice and any of the above may also be employed 
locally where the bleeding part can be reached, as about the nose and 
fauces. Plugging may be needed. 

Poulet has recently reported most glowingly of the effects of small 
doses (-5- grain in bread-crumb twice daily) of nitrate of silver. If his 
results are corroborated this will prove the best remedy we have. The 
writer tried this drug recently in a severe case where nearly all the 
previously mentioned agents had failed, and rapid improvement fol- 
lowed. There was nothing to lead him to believe that. any improve- 
ment was likely until after the silver had been administered. 

In the later stages tonics are indicated, and strychnine is of great 
value, combined with quinine, as in Easton's syrup. 

Complications which arise from the effects of internal hemorrhages 
are to be dealt with on general principles, and under some circum- 
stances opium may be needed. 

Faradization of the entire surface of the body is reported as having 
saved life in severe hemorrhage from purpura. 

When occurring in rheumatism, after large doses of iodides, or when 
undergoing the " raw meat cure," or in scurvy or other conditions, the 
indications for treatment are clear. The above remedies are only to be 
relied upon after the cause is removed or combatted. 

PUSTULE, Malignant— See Malignant Pustule. 
PYiEMIA. 

Like the treatment of puerperal fever, this form of septic poisoning 
calls for preventive measures, and in the vast majority of instances 
preventive treatment is as completely successful as ordinary treatment 
is valueless in the fully-established disease. 

The most rigid antiseptic treatment locally will be required in dealing 
with wounds and injuries, and absolute cleanliness and free drainage in 
all cases where an aseptic condition of the injured part is impossible. 
Pure air is of vital importance, and free ventilation must be maintained ; 
but the overcrowding of patients together in surgical wards will not be 
sufficiently met by ventilation alone. An abundant cubic air space 
must be supplied to each case. The wounds must be thoroughly irri- 
gated with antiseptics, and every trace of retained secretion must be 
washed out in this way, and, by free incisions, giving vent at the most 
dependent parts, and by the insertion of drainage-tubes retention of 
decomposing pus should be rendered impossible. Tension by these 



PYAEMIA. 783 

means cannot occur, and the frequent changes of the antiseptic dress- 
ings will prevent decomposition in the secretions. 

Gentleness in manipulation of skin wounds and in dealing with com- 
pound fractures is essential, and it is not necessary to say that sponges, 
soiled bandages, and every possible source of conveying germs from 
putrefying pus must be rigorously avoided. The bowels, bladder, and 
kidneys — in fact, all the excretory organs — should be kept in a state of 
activity. 

Internal accumulations of pus, especially when in connection with 
inflammation of bone, should be incised freely and early. As for drugs 
in the prophylaxis of pyaemia, there is certainly some efficacy in satu- 
rating the system of the patient with iron. 

Many years ago, when the writer was house surgeon and superin- 
tendent of a large hospital, he was satisfied that the routine rule which 
most of the surgeons adopted in putting every case with skin wounds 
or those for operation upon full doses of tincture of iron, had an appre- 
ciable effect in diminishing the risks of septicaemia, erysipelas, and 
pyaemia. This was before the introduction of the antiseptic method, 
when these affections were common. When pyaemia has once developed 
its characteristic symptoms, the prognosis is most grave, and little is to 
be expected from treatment in the great majority of instances. 

The question of secondary amputation, disarticulation, or the removal 
of any suppurating portion of the limb, or of the method practised by 
Lee of dividing any inflamed accessible vein between the heart and 
seat of original injury has been tried, and in some instances with suc- 
cess, when the operation was undertaken with promptitude in the very 
early stages. 

The treatment of all wounds should be the same as in the preventive 
stage, and every local accumulation of matter should be incised as soon 
as possible, the cavities washed out, and suitable drainage with anti- 
septic dressings applied frequently. 

Abscesses in joints should be opened at as early a stage as possible, 
washed out, drained, and dressed antiseptically, as if ordinary abscesses. 
The same remarks will apply to collections of pus in the pleura or 
pericardium. Every complication must be treated upon general sur- 
gical principles, in which the freest and most abundant supply of fresh 
and pure air is never to be forgotten. It is certainly worth while to 
attempt to surround the patient with an antiseptic atmosphere, and the 
writer has done this by making a muslin coverlet, and having it filled 
with teased-out oakum or carbolized tow, which is to be kept on the top 
of the patient's counterpane. Over this, after a brief period, as it 
loses its virtue by evaporation, turpentine, creasote, thymol solution, or 
eucalyptus, or other volatile antiseptic may be sprayed or sprinkled 
from time to time. Much can be done for some cases by diet and 
medication. The diet should be the most sustaining possible, and 
liquid nourishment should be pressed upon the patient with the view 



734 PYELITIS. 

of sustaining his vital powers to the fullest extent with the hope, that 
if kept alive for a time, the suppurative process may exhaust itself. 

Alcoholic stimulants are valuable, but they must be given with no 
sparing hand. The writer can recall cases in the pre-antiseptic period 
which were saved apparently by almost unlimited amounts of whiskey 
and port. Whiskey may be given with the milk, and half an ounce 
every hour is not a large amount when the very serious aspects of the 
cases point to its administration. A full dose given with some hot 
water at the commencement of the rigor affords relief, and often cuts 
short its duration. 

Of drugs, various antiseptics have been given, and the remarks 
applicable to the drug treatment of puerperal fever apply here. Qui- 
nine in full doses gives best results. The newer antipyretics act upon 
the temperature with greater certainty and precision, but quinine 
appears to be of value, even when it fails to reduce the fever heat. 

The following combination may be given : 

rx . — Quinine sulphatis 3jss. 

Tinct. ferri chlor. . . . ' . . . ^j. 

Glycerini purif. ^j. 

Aquse camphorse ...... ad ^xvj. — M. 

S. — Two tablespoonfuls to be taken, with as much water every eight hours. 

Iron, in full doses, is of great value in chronic cases. Salicin, sali- 
cylate of sodium, resorcin, iodoform, sulphites, sulpho-carbolates, per- 
manganate of potassium, creasote, turpentine, iodine, iodol, salol, and 
various other germicides have been administered internally as well as 
used locally, but with results which warrant little hope of success. 

PYELITIS 

The treatment of suppurative inflammation of the pelvis of the 
kidney will depend almost entirely upon the cause, and since this 
varies so greatly the treatment will necessarily be very various and the 
same remedies will seldom be indicated in any two cases, but there are 
some remedies which may be useful in all cases after the primary 
cause of the pyelitis has been removed. 

Where calculi in the pelvis of the kidney have been the cause of 
the affection little can be expected until these have heen removed (see 
under Stone in the Kidney), though some relief may be afforded by 
measures directed to the correction of any abnormal condition of the 
chemical constitution of the urine. When the affection is secondary 
to enlarged prostate, vesical calculus, gonorrhoea, chronic cystitis or 
tumors in the bladder, etc., the removal of the cause will lead to rapid 
subsidence of the pyelitis. When caused by cancer or tubercle 
nothing but palliative treatment need be thought of. Occurring 
during scarlatina, typhus, typhoid, smallpox, Bright's disease, diph- 
theria, diabetes, scurvy, or purpura, these affections will require appro- 



PYELITIS. 735 

priate treatment. Certain poisons or drugs, such as cantharides, tur- 
pentine, copaiba, etc., will cause pyelitis, which for the most part 
rapidly subsides after they have been discontinued. 

In acute cases where the cause cannot be determined or removed, 
absolute rest in bed is essential, and the free administration of bland 
mucilaginous drinks. Poultices, or hot sitz baths, warm fomentations, 
or all three combined may be used to relieve pain. Cupping, after the 
application of a dozen leeches to the loin, may be necessary. Mild 
diuretics, like the citrate of potassium, formed by giving a plain solution 
of bicarbonate ofpotassium in effervescence with fresh lemon juice, may 
be administered, but, as a rule, the use of ordinary diuretics, like squill, 
digitalis, copaiba, broom, etc., are to be condemned, and even buchu, 
uva ursi, pareira, and triticum, are to be given with caution. 

In some cases where the urine is markedly alkaline the mineral acids 
may be tried, but, as a rule, little need be expected from them. Boric 
acid is always safe and sometimes acts like magic, especially in those 
cases, acute or chronic, which have arisen from the extension of bladder 
mischief along the ureters. 

Pain may be relieved by hyoscyamus in full doses of the tincture in 
preference to opiates. 

In chronic cases the chief indication will be to diminish the secretion 
of pus, and to support the patient in every possible way by good feed- 
ing, cod-liver oil, pure air, improved digestion, change of scene, etc. 
Stimulants are to be given with caution. 

Of remedial agents next to the removal of the exciting cause boric 
acid, in doses of 15 grains three times a day, is by far the most 
efficient. 

When severe pain is present, it may be given in the following 
form : 

R. — Acidi borici .... i ... gr. x. 

Codeinse gr. + . 

Sodii salicylatis gr. x. — M. 

Make 24 of these powders. 
S. — One powder to be administered in half a tumblerful of effervescing 
potash water every six hours. 

Creasote, in the form of capsules each containing 1 minim, is of 
service, so also is quinine in full doses, 5 grains three times a day, 
combined with 30 minims of any of the mineral acids largely diluted. 
Sulphide of calcium has had a reputation in diminishing or check- 
ing the suppurative process within the body. It does not appear 
that it has any marked effect in modifying the suppurative action in 
pyelitis. 

Oil of eucalyptus offers a much more hopeful result, and it is much 
less likely to irritate than turpentine, which is the remedy still recom- 
mended by many authorities. 



736 PYELONEPHRITIS — P YO-PNEUMOTHOK AX. 

Tannic acid, benzoate of sodium, alum, iron alum, acetate of lead, 
Hydrastis, ergot, cantharides, and various other drugs are recom- 
mended, but their action is very doubtful. Perhaps the best effects 
after boric acid, if it fails, will be got by large doses of the tincture 
of chloride of iron. 

In some cases the operation of nephrotomy is the only hope of 
saving the patient, the kidney being incised through a skin wound 
made along the outer border of the erector spinse muscle, and 
thorough drainage established under strict antiseptic precautions. 
(See also under Hydronephrosis, page 374.) 

PYELONEPHRITIS. 

Arising from similar causes as are at work in pyelitis the suppura- 
tive process may attack the substance of the kidney. The treatment 
will be the same as that already mentioned under Pyelitis. 

PYONEPHROSIS. 

Where the passage of the ureter becomes blocked and pus accumu- 
lates iu the dilated pelvis of the kidney above the obstruction, the 
surgeon need not hasten to evacuate it. There is some reasonable 
hope that if the main line of treatment detailed under Pyelitis be 
rigidly carried out the purulent contents of the sac may dry up, and 
the entire organ be transformed into a semi-solid, harmless, inert putty- 
like mass, which in process of time may shrivel up into a membranous 
sac without any vestige of renal tissue in it. 

Where the tumor points, or where there is any chance of its empty- 
ing its contents into the peritoneal cavity or bowel it should be treated 
as an abscess upon general surgical principles and evacuated. 

Unless in urgent cases or for diagnostic purposes, aspiration is to be 
condemned. A free incision, with strict antiseptic precautions, should 
be made at the outer edge of the erector spinse muscle, midway be- 
tween the crest of the ilium and the last rib. From this wound all 
accumulations in the pelvis may be evacuated under the spray of 
carbolic lotion, and calculi or tumors may also be cleared out. A 
long rubber drainage-tube, with a broad flange on it, should be 
inserted deep into the sac, and the most efficient drainage secured. 

If, after a very considerable period, the wound shows no signs of 
healing owing to the continuance of free purulent discharge, before 
matters get too grave the patient should have the chance which a 
complete removal of the diseased organ will afford. 

P YO-PNEUMOTHOR AX. 

The treatment of this condition will be that of the empyema with 
which it is associated. (See under Empyema, page 236.) 



PYOSALPINX. 737 

PYOSALPINX. 

Various plans have been suggested for the relief or cure of sup- 
purative inflammation of or purulent accumulations in the Fallopian 
tubes. Often through the matter finding its way into the uterus and 
being discharged, relieving the patient permanently of further trouble, 
the like result may be hoped for before resorting to formidable opera- 
tions. When the symptoms are acute, absolute rest in bed, with ano- 
dynes and very copious" and very hot vaginal injections, are indicated 
as in acute metritis. 

In very chronic cases, where the degenerative changes in the lining 
membrane of the uterus has led to closure of the uterine end of the 
duct, the plan adopted by Doleris may be tried before resorting to 
laparotomy. The os is opened up by antiseptic tents, the interior of 
the uterus, and especially its Fallopian orifices, are thoroughly scraped 
by means of the curette, and antiseptic drainage established after 
packing the uterine cavity with iodoform gauze soaked in glycerin. 
This plan is very serviceable in simple catarrhal salpinx. 

The plan of using Brandt's massa ge with the view of emptying the 
contents of the tube into the uterine cavity is so fraught with danger 
as to be unjustifiable. In cases where it is certain that the uterine end 
of the tube is patent this procedure may be practised, but at the best 
it is of very doubtful value. 

Electricity by Apostoli's method has been extensively practised, 
and with marked success in some cases. The faradic current of 
tension he uses only in acute cases as a rapidly acting sedative, and 
the faradic current of quantity he considers only as indicated rarely 
in some very chronic cases. For the majority of cases the intra- 
uterine application of galvanism is indicated, and according to the 
strength of the current used any effect may be produced from a mere 
alterative action to thorough and complete galvano-cauterization. It 
is this last result which is aimed at so as to cause destruction of the 
mucous membrane as effectually but more safely than by the curette 
as just described. The positive pole should be introduced into the 
uterus at first, and the negative only after several sittings. Every 
five days, 5 minutes of galvano-cauterization, with a current com- 
mencing 50 and reaching 150 milliamperes, may be administered. 

Where the above measure fails, the operation of vaginal galvano- 
puncture is indicated. Apostoli says that " almost every salpingo- 
oophoritis will be amenable to appropriate electrical treatment. It is 
sovereign in the catarrhal salpingites, calming in the tuberculous 
salpingo-oophorites, and capable of curing certain purulent forms of 
salpingo-oophoritis by the establishment of vaginal drainage." The 
latter result is obtained by burying for the depth of less than half an 
inch a small sharp steel trochar in the part of the inflammatory tumor 
which is most prominent in the vagina, avoiding the anterior cul-de-sac. 

The positive pole should be first employed, and later on, especially 



738 RANULA. 

when a vaginal fistula is desired, the negative should be employed ; a 
current up to 250 milliamperes may be used. The strictest antiseptic 
precautions are necessary, and rest in bed is essential. 

McClure, instead of the galvano-puncture, prefers the metal ball 
electrode (negative) covered with wash leather, and applied per vagi- 
nam directly to the mass to be acted upon, using a current of up to 
100 milliamperes for ten minutes every three or four days. 

Various operative measures have been practised by surgeons, the 
most recent of which is that practised by Skutsch, who removes the 
contents of the tube after puncturing with a Pravaz syringe. If the 
contents are clear and free from pus, he opens the ostium and cuts out 
of the wall of the tube in its vicinity a small oval piece, and unites 
by sutures the mucous and serous membranes around the aperture thus 
formed. In cases of pyosalpinx, he sutures the end of the diseased 
tube in the abdominal incision. 

The tubes may be removed by a small abdominal incision, and if any 
of their contents escape, the peritoneal cavity must be thoroughly 
irrigated and drainage established. Some operators have removed the 
tubes per vaginam. 

When the tubes are bound down in the pelvis by adhesions which 
would render their entire removal by abdominal section hazardous, the 
plan which has been successfully practised by several surgeons may be 
tried. The tumor in this case may be aspirated from the vagina, but 
as a rule this will give but temporary relief, the fluid soon accumulating 
again. The best practise would seem to be to make a free incision 
into the tumor from the vagina, and wash out the cavity with a mild 
antiseptic, and inject afterward with iodine, establishing drainage when 
necessary. 

PYROSIS— See Dyspepsia. 

QUINSY— See Tonsillitis. 

RABIES— See Hydrophobia. 

RACHITIS— See Rickets. 

RANULA. 

Upon the whole, the most satisfactory method of dealing with these 
cysts is to snip out a small window-like piece of the cyst wall and 
mucous membrane in the floor of the mouth, and pack the cavity with 
a little absorbent wool soaked in iodine (1 : 20), strong solution of 
chloride of iron, or chloride of zinc, with the view of exciting inflam- 
matory action. 

The opening may require to be enlarged with the scissors if it closes 
too rapidly. The writer has treated many small ranulse by simply re- 
moving as much of the anterior wall as possible with a fine, sharp- 



KELAPSING OR FAMINE FEVER. 739 

pointed pair of scissors, and leaving the gap to close up by natural 
means. Excision of such cysts is most difficult, and rarely necessary ; 
and the establishment of a permanent fistula is equally difficult in 
some cases, unless Dupuytren's seton instrument be used. In congen- 
ital cases the cyst may be tapped and rubbed with the solid nitrate of 
silver. 

RAYNAUD'S DISEASE. 

The uncertainty about the pathology of this form of gangrene ren- 
ders a rational method of treatment difficult. The object should, as 
far as possible, be to determine the underlying cause of the arterial 
spasm, and remedy it by appropriate agents. Thus, in the cases where 
a syphilitic history is evident, the condition has rapidly disappeared 
after the exhibition of anti-syphilitic remedies, and where Bright's dis- 
ease, diabetes, alcoholism, injuries to the abdomen, meningitis, mania, 
emotional disturbances, exposure to cold, leprosy, hsematinuria, etc., are 
probably exciting causes, these conditions should be met by the recog- 
nized remedies. The local treatment will depend upon the condition 
of the affected parts. (See Gangrene.) In Professor Smith's interest- 
ing case the treatment consisted in the administration of 10 grain doses 
of antipyrine for the first three days, and afterward, of a mixture con- 
taining arsenic and strychnine every six hours. 

RECTUM, Cancer of— See Cancer. 

RECTUM, Inflammation of— See Proctitis. 

RELAPSING OR FAMINE FEVER. 

As the name implies, this scourge is associated with starvation in 
most epidemics, and the treatment must be chiefly sustaining. Though 
distinct from typhus, it management may be briefly described as that 
which would be suitable in a smart attack of that fever occurring in 
a broken down patient. 

Abundance of liquid and easily digested food, administered cautiously 
at first; Alcoholic stimulants, to be given as indicated by the pulse and 
collapse ; quinine, for the high temperature ; and rest in bed after the 
fall in the fever, and the steady administration of every sustaining 
agent, so that, if relapse occurs, the patient may be well prepared for 
the further drain upon his vital powers, are generally all that will be 
necessary to tide the patient over the attack. 

Dysenteric and pulmonary complications are indications for the con- 
tinuance of quinine and alcohol. In future epidemics it may be found 
that the intense pain in the back and head may be safely relieved by 
small doses of antipyrine, and that hyperpyrexia may be promptly 
reduced by the cold bath. 



740 REMITTENT FEVER. 

REMITTENT FEVER. 

The treatment of this affection is to be conducted upon the same 
general principles as are indicated in intermittent fever. The sovereign 
remedy being quinine in large doses, any other preparation of cinchona 
may be substituted in special cases with more or less advantage ; but 
the sulphate of quinine is the one still most generally used, and it may 
be given by the mouth or rectum. In the early stage of the disease, 
until the occurrence of the first remission proves to the physician the 
nature of the disease with which he is dealing, ordinary diaphoretics, 
as spirit of nitrous ether, alone or combined with small doses of tinc- 
ture of aconite, will probably suggest themselves, or moderate doses of 
antipyrine may be used. A good purge — 5 grains of calomel — is a 
favorite dose with those experienced in dealing with the early stages 
of suspected malarial fevers. 

Once the remission has occurred there should then be no time lost in 
administering quinine ; 30 grains should be given in divided doses of 
5 or 10 grains inside an hour. When vomiting is severe and incessant 
30 or 40 grains may be given by the rectum. This dose will occasion- 
ally be all that is necessary in mild cases, and may effectually prevent 
further exacerbations ; but, as a rule, it will be advisable to keep the 
patient under its influence for some time, and for this purpose some 
physicians begin with 5 grains of quinine, and continue this dose 
through fever and remission until cinchonism is produced. When 
given during the exacerbation vomiting is much more likely to occur, 
and many prefer to only give the drug during the remissions, continu- 
ing it until the fever ceases to rise. Upon the whole, perhaps, the best 
plan is to give one dose of 20 grains during the remission, and to keep 
up the effect by doses of 5 grains during the exacerbations as long as 
the temperature keeps high. 

Hyperpyrexia, which sometimes occurs in severe cases, will not be 
met by quinine. The newer antipyretics or salicylic acid may be tried ; 
but it is wiser, in the face of a (rising) temperature above 106°, to 
resort without delay to the cold bath or cold pack. Warburg's tinc- 
ture is often useful in cases where these remedies are not permitted. 

Collapse, vomiting, diarrhoea, intense headache, restlessness and other 
complications of symptoms, are to be met by remedies which, under the 
same circumstances, would be indicated in typhus or typhoid fevers. 
It is needless to say that bleeding, leeching, purging, mercurialization, 
emetics, and other lowering treatments are not to be thought of. 
Arsenic is of use in the later stages. 

RENAL COLIC— See Stone in the Kidney. 

RENAL DISEASE— See Bright's Disease, Pyonephrosis, etc. 



RETENTION OF URINE. 741 

RETENTION OF URINE. 

For the relief of a distended bladder the hot bath and catheter are 
the appropriate remedies. The history of the case will generally give 
at once some idea of the cause. Thus in a patient in advanced life 
with a history of failing power in emptying the bladder, and in the 
absence of a history of stricture, enlargement of the prostate is almost 
certain. Here, as already mentioned under Prostate, Enlargement of, 
page 707, the surgeon should attempt to pass a pure vulcanized rubber 
instrument of about the size of a No. 8 or 9 (English). The catheter 
should not be passed until the patient has been placed in a hot bath, 
and often micturition occurs in hospital cases especially after twenty 
or thirty minutes in the bath. When the rubber instrument fails, the 
gum-elastic or French coude may be tried. The writer, after failing 
with the rubber, generally finds that a large-curved silver instrument 
is the best in acute cases. With skill and confidence this weapon will 
seldom fail in entering the bladder. The novice is almost certain to 
try the smaller sizes, but a No. 10 long (English) silver catheter with 
a wide curve is the proper instrument. 

Regarding the plans for passing it safely into the bladder little need 
be said, as a little experience is worth volumes of written directions. 
The catheter should be rendered aseptic inside and out, and it should be 
well oiled, and the greatest patience and gentleness are essential, and 
sometimes the introduction of the left index-finger into the rectum will 
greatly assist the passage of the instrument. 

Where the difficulty of introducing an instrument is very great, 
especially when some previous operator has succeeded in making a 
number of false passages, it will be necessary after its introduction to 
tie in the instrument for a time (the tying in of a silver catheter is, 
when possible, to be avoided). 

When getting into the bladder is impossible, after reasonable patience 
has been exercised, and where the patient urgently requires relief, his 
bladder may be tapped by the aspirator above the pubes — a simple 
and safe operation, after which often a rubber catheter can be then 
passed through the urethra and tied in for several days, antiseptic pre- 
cautions being attended to. (See under Prostate, Enlargement of, 
page 706.) 

Where the retention is the result of stricture, and the history of the 
case leaves no doubt of the diagnosis, the surgeon should keep clearly 
before his mind the pathology of this affection. In this lies the secret 
of successful treatment. A few hours before the attack of retention 
probably the patient passed his urine freely, though in small stream. 
The element of spasm and swelling of the urethral mucous membrane 
from some recent chill or irritant is the exciting cause, and affords the 
explanation of the sudden blocking up of the urethral canal. 

When time permits, these causes should, if possible, be combated by 
a hot bath and a full opiate before resorting to the use of the catheter. 



742 RETINITIS. 

After the failure of these the patient should be put to bed, and a 
No. 1 or 2 gum-elastic instrument without a stylet should be passed 
down to the stricture, and with patience and gentleness it may be coaxed 
through. After the opening up of the anterior portion of the stricture, 
the writer has often succeeded in passing in a No. ? or a No. 0. Where 
these fail a No. 1 silver instrument may be tried, but in inexperienced 
and rough hands this is a dangerous weapon, as every hospital house 
surgeon knows. When the bladder is entered and the urine drawn off, 
the instrument should be tied in, and the greater the difficulty experi- 
enced in passing it, the more reason is there for tying in the catheter, 
so as to avoid further irritation when the bladder again fills. After a 
few days a larger instrument may be passed and tied in, and the routine 
treatment for stricture may be then commenced. 

Where the bladder cannot be relieved by the urethral route, it may 
be punctured with the aspirator needle above the pubes, or a supra- 
pubic opening may be made by a long curved trocar and canula, which 
may be retained for a few days, or the bladder may be opened by the 
rectal route, or by the button-hole perineal opening, known as the 
operation of Boutonniere. (See under Stricture of the Urethra, Uri- 
nary Fistula, etc.) 

Where the retention is caused by a small impacted calculus this 
should be removed by suitable forceps, or if too close to the bladder, a 
gum-elastic or silver catheter may be gently worked past it. 

Where swelling or inflammation of the urethra, as in gonorrhoea, is 
the cause of retention a very hot bath and a warm urethral injection 
of distilled water with a smart saline purge, and, if necessary, leeching 
the anterior portion of the perineum may be tried, after which a rectal 
injection of 30 minims of laudanum or the introduction of a morphine 
suppository may be resorted to. In unyielding cases a medium-sized 
soft-rubber catheter may be introduced. 

In hysterical retention, or in retention owing to temporary paralysis 
of the bladder, as in fevers, and after accidents or opium, a soft-rubber 
catheter is the best instrument for drawing off the accumulated secre- 
tion. Where nothing complicates the hysteria, the use of the catheter 
should not be resorted to until moral treatment, the free use of the 
cold douche, and other anti-hysterical remedies have proved unsuc- 
cessful. 

RETINITIS. 

In simple inflammation of the retina little can be. done but to insist 
upon absolute rest and the exclusion of light, and mild counter-irrita- 
tion above the brows or on the nape of the neck, and to search dili- 
gently for the constitutional affection upon whose presence the retinitis 
depends and treat it. 

In albuminuric retinitis the treatment should be directed to the con- 
dition of the kidney, and the various remedial measures are detailed 
under Bright's Disease, upon page 78. 



RHEUMATIC ARTHRITIS (CHRONIC). 743 

In syphilitic retinitis small doses of the bichloride of mercury, after 
a course of iodide of potassium, will afford the best hope of cure or 
amelioration. 

In the pigmentary form the mildest continuous current often does 
good. 

RETINAL DETACHMENT. 

The treatment of this troublesome affection is often most unsatisfac- 
tory and tedious. The only cases where any very marked improvement 
may be confidently expected are those in which the patient comes early 
under the physician's care; and under these circumstances the course 
to be pursued is clear. Rest is the one most important and essential 
element in treatment. The patient should be confined to the horizontal 
position in a darkened room, with a moderately tight bandage over 
the eye. Diuretics and saline cathartics may be advantageously used, 
and when the amount of sub-retinal fluid is large a puncture should be 
made in the outer coat of the eyeball and the fluid drained off. There 
does not, however, appear to be much benefit from this procedure after 
the reaccumulation of the dropsy, though when adopted early in large 
extravasations the results are good. 

Pilocarpine in full hypodermatic doses has certainly been followed 
in some instances within the writer's knowledge by very marked im- 
provement. The full physiological action of the drug must be induced 
and the injections repeated daily or every second day for many weeks. 

RETROFLEXION AND RETROVERSION — See Uterus, Dis- 
placements of. 

RHEUMATIC ARTHRITIS (Chronic). 

If treatment be commenced early much may be done for this obsti- 
nate malady. In a fair percentage of cases the joint troubles may be 
caused to entirely disappear, but this need never be expected unless 
the patient can be completely removed from his surroundings and 
transported to a drier atmosphere, where the variations of temperature 
are less marked than in this changeable climate — a warm, dry, equable 
climate being acknowledged on all hands to be an essential factor in 
successful treatment. 

As a winter resort, Algiers, Egypt, and Italy are suitable, while in 
summer Baden-Baden and Weisbaden and other Continental resorts 
are popular. In connection with these places the baths are of great 
importance, but these will be mentioned later on. 

Clothing and diet are also of vital importance. As regards the 
former, the body should be encased in light woollen garments, worn, if 
possible, next the skin, but overclothing is to be avoided. The writer 
advises a thin flannel vest and drawers, with a piece of wash-leather 
inserted inside the fabric next to the skin, over the large joints, as at 



744 RHEUMATIC ARTHRITIS (CHRONIC). 

the shoulders, elbows, and knees. The practice of piling on garment 
over garment, so as to keep the patient always in a state of perspira- 
tion, is to be condemned. The feet-wear is not to be neglected, and 
cork insoles are essentials in wet weather. All undue exposure to 
cold and damp, it is needless to say, should be avoided, and the 
patient should be advised, if possible, not to expose himself during the 
prevalence of east winds. 

As regards diet, everything which tends to improve nutrition must 
be freely given. _N"o matter which of the various views of the path- 
ology of the affection may be accepted, there is always evidence of 
serious impairment of nutrition, and this calls for the most liberal and 
varied dietary. Mixed food — fresh meat and plenty of fresh vege- 
tables — with a very limited supply of malt liquor or none at all, 
should form the basis of food. 

Celery, eaten raw or stewed, is a popular remedy, and experience 
proves that there is some truth in the belief, though the writer thinks 
that the Spanish onion is the best of all vegetables for constant use by 
the victims of this affection. In Ireland, where the disease is so very 
common, it is probable that the excessive use of bacon has something 
to answer for in inducing the disease. 

Fats are an important item in the dietary, and above all other foods 
or drugs stands cod-liver oil. It should be regarded not as a medicine, 
but as a food, and, in conjunction with the extract of malt, should be 
given at the termination of every meal. 

In hereditary cases, when rheumatic or arthritic pains first show 
themselves in the offspring of parents in whom the disease is well 
marked, this food or drug should be pushed. The writer has seen good 
results from this remedy even in obese subjects. 

Sometimes an impression has been made upon the disease by a pro- 
longed trial of a purely vegetarian diet. 

Every error or departure from the normal standard of health must 
be carefully sought for, and remedied as soon as discovered. Thus, 
prolonged mental exertion, worry, super-lactation, menstrual disorders, 
frequent pregnancies, and renal disease, may be found to be the exciting 
causes. 

Medicinal treatment in the more acute form of the disease may be 
tried upon the lines laid down in Acute Rheumatism, but, as a rule, 
the salicylic compounds are of very little use, certainly of no permanent 
use whatever. Those writers who report great benefits from their 
administration probably do not differentiate carefully between acute or 
sub-acute rheumatism and rheumatic arthritis. In the North of Ire- 
land, where this latter affection is seen not rarely in hospital in a more 
or less acute form, a differential diagnosis may generally be made by 
watching the failure of the salicylates, which are almost certain to 
speedily relieve articular rheumatism. 

Alkalies are always of some use, and large doses of iodide of potas- 
sium may be combined with them for the relief of the pains in the early 



RHEUMATIC ARTHRITIS (CHRONIC). 745 

stages of the more acute cases. Antipyrine and quinine, alone or in 
combination with opium, may be resorted to in such cases. 

Various anodyne applications may be used for the relief of pain 
when this is severe in recent cases. 

For the ordinary chronic cases which come under observation only 
after the disease has existed for some time, there has been a very long 
list of remedial agents recommended, but if all be excluded save those 
which have stood the test of experience the list will become a very 
limited one, and will be made up of the following in their order of 
merit : cod-liver oil (already mentioned as a food), arsenic, iodine, sul- 
phur, guaiacum, actsea racemosa, and iron. 

In conjunction with these, and of considerable value, must be 
bracketed electricity (the continuous current), massage, various medi- 
cated baths and spas. 

While great benefit, and even permanent success, follow the use of 
these measures in some cases, nevertheless one after another of them 
may be tried in vain. Generally, however, failure may be attributed 
to the patient who soon loses faith in remedies, and flies from one 
quack preparation to another until the joints have become hopelessly 
deformed. 

The writer recommends the steady administration of a combination 
like the following for several months : 

R. — Liq. potass, arsenit £>ijss. 

Potass, iodidi ' ^vss. 

Ext. sarsap. fid. ' ad ^viij. — M. 

S. — One teaspoonful in a wineglassful of water to be taken three times a day 
after meals. 

This may be given in conjunction with a dose of cod-liver oil after 
dinner and at bed-time. 

The syrup of iodide of iron is a favorite preparation, but in the 
writer's hands it has generally failed. The plain tincture of iodine is 
better. 

The old electuary known as the " Chelsea Pensioner," containing 
sulphur, guaiacum, rhubarb, nitre, mustard, and honey, often relieves 
pain and checks the progress, of the disease. (See page 430, fifth edi- 
tion of Pharmacy, Materia Mediea, and Therapeutics.) 

Actsea racemosa, in full doses, often affords some relief. Ringer 
thinks it acts best in those cases where the uterine functions are dis- 
turbed. 

The weak, continuous current (15 to 25 Leclanche cells) used twice 
a day in conjunction with any of these drugs is of much service. The 
sponge electrodes being well moistened in hot salt and water, one is 
placed just above the affected joint, and the other over the skin at any 
part of the limb lower down. Even the induced or interrupted cur- 
rent has been found useful. 

48 



746 RHEUMATIC ARTHRITIS (CHRONIC). 

Massage often proves valuable, especially in those cases where walk- 
ing exercise is painful or impossible, and it may be employed along 
with the use of electricity, but its best results are obtained when it is 
carried out in the Turkish bath by a skilful operator. 

In very chronic cases it is sometimes astonishing to observe the good 
which may follow simple passive movements of the affected joints, and 
by this procedure deformity, pain, stiffness, and anchylosis may disap- 
pear, even in bed-ridden patients. 

Among baths, the warm, sulphurous waters are especially to be 
commended, and various other saline baths are of undoubted value. 
Harrogate, Buxton, Bath, and Strathpeffer have their advocates ; 
Aix-la-Chapelle, Aix-les-Bains, Baden-Baden, Wiesbaden, Pyrmont, 
and many other Continental waters are of great value. The hot brine 
baths of Droitwich, with massage, are, in the writer's opinion, of the 
greatest service in many cases, and the good effects may be kept up 
when the patient returns, by the steady use of the Turkish bath at 
home during the winter months. 

This treatment is of service where all the joints are involved, but 
the best results are seen in those cases where a limited number of the 
large and medium-sized articulations are affected. 

Hot douches (especially the hot sulphurous douche), cold douches, 
mud or peat baths, or the bath made by enveloping or burying the 
affected joints for one or two hours daily in very hot sand, have been 
recommended, and after their use, passive movements or massage may 
be tolerated, when these agents were before contra-indicated by the 
amount of pain and distress produced by the friction and motion. 

Of local applications for the relief of pain there is practically no 
end. Every known form of counter-irritation has been tried, and any 
application which is capable of causing an increased flow of blood to 
the skin may be used. Most of the good which has been experienced 
from local remedies has been the result of the friction and massage 
associated with their application. 

Chilli paste, turpentine, paraffin oil, camphor, ammonia,, cajuput or 
eucalyptus oils, the official liniments of soap, ammonia, compound 
camphor, croton oil, iodine, mustard, turpentine, or acetic turpentine, 
may be employed. The liniments of St. John Long and Stokes are 
popular remedies. Arnica should never be used. 

Of local anodynes for the relief of pain, when this is very severe the 
liniments of chloroform, belladonna, and tincture of aconite in equal 
proportions applied upon the lint and covered over with oiled silk, is 
one of the most efficacious. The joints may be wrapped up in a thick 
layer of absorbent wool, and covered with thin mackintosh, kept in its 
place by a moderately tight bandage. 

New flannel, dusted over with flowers of sulphur, is a popular and 
valuable remedy when used as a bandage to envelop the affected 
joints. Chaulmoogra oil, cod-liver oil, oleate of mercury and mor- 



RHEUMATISM, ACUTE. 747 

phine, and other agents have been used in conjunction with massage, 
or strapping of the joints with stout plaster. 

Where local remedies fail to give relief to the wearing pains of 
chronic rheumatic arthritis, opiates, antifebrin, antipyrine, exalgine, 
large doses of bromide of potassium, colchicum, lithium, salicylate of 
sodium and quinine salicylate, may be tried if the previously-mentioned 
internal remedies have failed. 

RHEUMATISM, Acute. 

Upon the first symptoms of pain, heat, and redness in one or more 
joints, with increased temperature and sweating, the patient should 
be ordered off to bed without a moment's delay. There is, perhaps, 
no other diseased condition where absolute rest in the horizontal posi- 
tion is more clearly necessary. Endocarditis, followed by permanent 
valvular mischief, is decidedly less likely to occur in patients who 
have taken early to bed after the development of rheumatic fever. 

The sick room should be selected upon the ordinary sanitory prin- 
ciples, and it is better that it should not be upon the ground floor. 
The air of the room should be kept at a uniform temperature, and 
currents of cold atmosphere are to be avoided ; hence ventilation by 
the windows is not advisable. The dry heat given out by a really 
good Fletcher's gas stove or a Tait's thermic ventilator is a desidera- 
tum. The bed should consist of a good hair mattress upon the top of 
a hard straw palliasse, feather beds being objectionable, both on ac- 
count of the patient sinking into them and also of his profuse sweat- 
ing. Sheets (especially linen) must be dispensed with, and it adds 
greatly to the comfort of the patient if he be placed between light or 
thin flannel blankets. The bedclothes should not be abundant, and a 
loose and thin flannel night dress, which speedily absorbs the cuta- 
neous moisture, is to be preferred to calico or cotton. Loosely-fitting 
drawers of the same material may also be worn. A bed-pan and 
urinal are # essentials. A common pickle bottle makes a convenient 
urinal. 

The diet may with advantage consist entirely of milk, with farina- 
ceous food occasionally, and at a later stage beef tea, soups, chicken 
jelly, or concentrated beef essences may be administered after the sub- 
sidence of joint pains and fever. Thirst may be relieved by small 
quantities of ice sucked in the mouth, or by the frequent administra- 
tion of a wineglassfull of equal parts of iced kali water, and milk, or 
by lemon juice diluted with three or four parts of water. Alcoholic 
stimulants are not generally required. Cardiac weakness and various 
complications, such as pleuritis or pneumonia, may, under certain cir- 
cumstances, call for them in full doses. 

Of drugs, there is no remedy equal to the salicylates, and, though 
some eminent authorities recommend a pure expectant or peppermint 
water treatment, and publish excellent results from its use, neverthe- 



748 

less it is highly probable that these savants would resort very soon to 
the salicylic treatment, should they themselves be unfortunate enough 
to become the victims of an acute attack of rheumatism, with its 
unbearable pains and aches. 

Those who recommend aconite, veratrum viride, and cimicifuga have 
more claim to be heard, and there is no doubt that small doses of these 
drugs have a decided influence in modifying the fever and alleviating 
the joint pains. One minim of the U. S. P. tincture of aconite, given as 
soon as the patient comes under notice, and followed up by i minim 
every thirty minutes for six or eighth hours, often affords considerable 
relief, and in mild cases appears to cut short the attack", but in many 
cases such treatment fails entirely. 

The writer would go so far as to state that, given a typical case of 
severe acute rheumatism, the physician is not warranted in withhold- 
ing the salicylic treatment, and, since those who begin with aconite 
and other agents generally fall back upon the salicylates, it would 
appear more rational to lose no time, but to put the patient at once 
under their influence, and save him all the suffering possible. 

The literature of the salicylic treatment since its introduction by 
Maclagan would fill a small library, and volumes might be made up 
of statistics attempting to prove its efficacy or its failure in influencing 
the duration of the disease and its effects upon preventing or determin- 
ing cardiac complications. Under the head of Endocarditis these im- 
portant points have already been referred to, and only brief mention 
can be made of them here. 

It cannot be denied that the salicylic treatment affords the most cer- 
tain and speedy means by which all the symptoms of acute rheumatism 
may be relieved, but it must be granted that it still remains to be 
proven that this treatment has the power of cutting short the actual 
duration of the disease to any considerable extent. As regards the 
effect upon the cardiac complications likely to occur during the attack, 
it must again be admitted that clear proof is still wanting to demon- 
strate that it lessens to any appreciable degree the occurrence of endo- 
or pericarditis. 

By closely watching the cases long after recovery, the writer believes 
that it may be possible to prove that of a number of patients who have 
suffered from rheumatic endocarditis, a smaller percentage of those 
who had received salicylic treatment will eventually develop permanent 
valvular mischief than of those subjected to expectant or other methods. 
This is obviously a very difficult point to settle, but of late years the 
results of hospital and private cases (but chiefly the latter) have led 
the writer to gravitate toward a conclusion in favor of the permanent 
benefit arising from the salicylic treatment. 

It does not appear that these remedies prevent relapses, and indeed 
it would seem upon the contrary that relapses are, if anything, more 
frequent than when the alkaline treatment is alone used. This may 
be, however, owing to the patient indulging in exercises or movements 



749 

while the pains are in complete abeyance under the influence of the 
salicylates before the attack has entirely passed off. 

The various drugs embraced under the general term of salicylic 
lemedies include salicin, salicylic acid, oil of wintergreen, salicylate of 
sodium, and salol. 

Maclagan recommended salicin, some still adhere to the acid, but 
the great majority of physicians rely upon the salicylate of sodium, and, 
upon the whole, it is in many points of view the drug best suited to 
the great bulk of cases. Salol in full doses is dangerous owing to its 
high percentage of carbolic acid. 

The able researches and invaluable discovery of Professor Charteris, 
who has isolated a substance from the artificial acid and its sodium salt, 
which he has experimentally demonstrated as being the cause of cer- 
tain toxic effects noticed after large doses of these substances, have 
placed the salicylic treatment upon a surer foundation. Only the acid 
or its soda salt as purified, by his method should ever be used in medi- 
cine, and much larger doses than those hitherto employed may now be 
given with perfect safety. 

Thirty grains of the purified salicylate of sodium may be given as soon 
as the patient comes under observation, and 20 grains may be given 
every four hours afterward. In twenty-four hours after the inaugura- 
tion of this treatment often all fever has disappeared, and the joint 
trouble may be noticed to have entirely given way. These effects have 
been happily described by Professor Quinlan, who states, as the result 
of his experience in rheumatic fever, that " by giving or withholding 
salicylates we can turn 'off' or ' on ' the fever as we do a gas tap." In 
the writer's wards the students complain that they never see " rheu- 
matic fever," as the symptoms and signs of the disease are, as a rule, 
entirely removed by the salicylic treatment before they get a sight of 
the patient. 

Some physicians prefer to give 15 grains of the soda salt every hour 
for four or five doses, then every three or four hours, but each case 
may be treated upon its merits, and as the temperature falls the amount 
and frequency of the dose may be diminished. The best plan will be 
to proportion the size of the dose to the length of time from the com- 
mencement of the patient's illness until he came under observation. 
Thus, given a patient ill for several days with many joints affected, it 
will be well to save time by giving 30 grains of the soda salt imme- 
diately, and 10 or 15 grains every two or three hours, according to the 
effect upon pain and temperature. Fifteen grain doses three times a 
day should be given for a week after the subsidence of the pain and. 
fever. 

Salicin may be given in wafer papers containing 15 or 20 grains 
each, and a favorite method of administering the pure acid is to give 
20 or 25 grains in half an ounce of mindererus spirit. The soda salt 
has a most unpleasant taste when given in ordinary mixture containing 
flavoring syrups or other ingredients, and by far the best plan is to 



750 

prescribe it in the form of powders, each containing 15 to 30 grains, 
to be given in effervescing kali or potash water. The advantages of 
this plan are obvious — it is more palatable, and it combines the sali- 
cylic treatment with the alkaline. These remedies should be stopped 
or suspended for several hours as soon as their full physiological effects, 
as buzzing in the ears, deafness, etc., are established. 

Alkalies have been long the recognized remedies in the treatment of 
acute rheumatism, and it is to be feared that their value is becoming 
lost sight of since the introduction and general use of their more 
speedily acting rivals— the salicylates. 

It is claimed for them that they act as specifics or antidotes to the 
rheumatic poison which has long been regarded as an acid substance, 
and though the progress of pathological research appears to point in a 
different direction, nevertheless experience has established the empiric 
fact that these agents exert a most beneficial effect upon the intensity, 
duration, and complications of acute rheumatism, and it is affirmed by 
some that they tend to prevent cardiac mischief to a marked extent. 

The bicarbonate of potassium is the salt generally selected, and it 
should be given in doses sufficient to rapidly render the urine alkaline. 
Thirty grains may be given every three or four hours, and after the 
effect upon the renal secretion has been thoroughly established, 15 or 
20 grains four or six times a day may be given for many days, or even 
for several weeks until the disappearance of pain and fever indicates that 
the disease has exhausted itself. 

The addition of citric acid or fresh lemon -juice to each dose of the 
alkali in no way diminishes its good effects, and where a more decidedly 
alkaline action is desired the tartrate or acetate of potassium may also 
be given. 

Garrod's plan of treatment consists in giving full doses of quinine 
(5 grains) in conjunction with alkalies every three, four or five hours. 
This is known as the modified alkaline treatment. 

Perhaps the best of all methods of dealing with acute rheumatism 
is the plan followed by the writer, and probably by many others. It 
consists in full doses of the salicylates, as already mentioned, until a 
rapid impression is made upon the pyrexia and joint pains. This 
occurs generally within twenty-four hours, after which time the dose of 
salicylate is diminished by about one-half, and a moderate dose of 
alkali added, the combination of alkali and salicylate being kept up 
for many days after the disappearance of the fever and joint troubles. 

The bicarbonate may be given in the form of a strong aerated potash 
water (30 grains to 10 ounces), to which the salicylate is added just 
before swallowing, or 20 grains of the bicarbonate may be added to 
half a tumblerful of ordinary potash water, in which 20 grains of 
the salicylates have been dissolved, or the following mixture may be 
ordered : 



RHEUM ATISMj ACUTE. 751 

R.— Sodii salicylate 3iv. 

Potassii bicarb. 3yj. 

Morphinse hydrochlor gr. j. 

Aquae camph 3 xv j — M. 

S. — Half a wineglassful to be taken four times a day. 

Or the following plan may be adopted : 

R . — Potassi bicarb ; . . gvj. 

Aqure dest ^xij.— M. 

S. — One of the powders (>. ?., 20 grains salicylate of sodium) to be dissolved in 
two tablespoonfuls of this mixture, after which an equal quantity of lemon-juice 
is to be added, and the whole to be taken during effervescence, every four hours. 

Lemon-juice alone in large quantities have. been used by Owen Rees 
as a means of treating acute rheumatism through all its stages. It is 
doubtful if it possesses any specific virtues, but in the form of citrate of 
potassium its utility is established. As the free juice can do no harm, 
and as it affords a pleasant drink to the patient, it may be freely given, 
even to the extent of the juice expressed from a dozen lemons daily. 
This may be administered alone, diluted with water, or better still, 
mixed with an equal quantity of kali or potash water. In prescribing 
the various alkaline or salicylic compounds in the form of effervescent 
mixtures in rheumatic fever, it is advisable to order more lemon juice 
or citric acid than is merely necessary to saturate the alkali. The recipe 
given upon the previous page affords a method of combining the lemon- 
juice, alkaline, and salicylic plans of treatment. The citrate of potas- 
sium, resulting from this combination of agents, is converted into the 
carbonate in the system, and increases the alkalinity of the blood. 

Iron, in the form of large doses of the tincture of the chloride, has 
been advocated by Reynolds and some others, but their results, read in 
the light of the natural tendency of acute rheumatism to cut itself 
short or to abort in many cases, do not appear to justify its use. 

Antipyrine and antifebrin have been recently tried, and in some 
instances have given excellent results, as the reports of Guttmann 
show. The pain and fever rapidly yield to 15 grain doses of the for- 
mer and to half the quantity of the latter drug. The effects, though 
more rapid, are less lasting than those obtained from salicylates, and 
their proper place in the treatment of acute rheumatism appears to be 
where salicylates fail, and it must be acknowledged this is seldom. 

Where the temperature is high and, notwithstanding the free admin- 
istration of natural or purified salicylates, it continues to ascend and 
hyperpyrexia is feared, these drugs may be given sometimes with 
benefit after the suspension of the salicylates. 

The introduction of the purified acid will permit of very large doses 
being given without unpleasant results following, and hence it is highly 
probable that cases of acute rheumatism which fail to yield to salicy- 



752 RHEUMATISM, ACUTE. 

lates will become extremely rare, and hence the range of the newer 
antipyretics will be exceedingly limited in this disease. 

Antifebrin seems to give better (more lasting) results than the anti- 
pyrine, and in the rheumatism of children may be tried where an 
analgesic effect is needed or where the profuse sweating caused by 
salicylates cannot be tolerated. Small doses of antifebrin (5 grains) 
the writer has seen to reduce temperature and relieve pain, without 
producing any appreciable increase in perspiration, in some cases. 
Latham insists upon the advantage of giving the true salicylic acid 
without any alkali or base. He makes a pill mass of 100 grains of 
the natural acid, with 15 grains acacia gum and a little mucilage. 
This he divides into thirty pills, and gives six every hour until buzzing 
of the ears occurs, then six every four hours. He attaches great 
importance to occasional doses of calomel. 

In hyperpyrexia all these antipyretics generally are not to be relied 
upon. 

Phenacetin has been given under similar circumstances, and though 
much vaunted as an analgesic and antipyretic, it remains to be proved 
whether it is equal in value in the treatment of acute rheumatism to 
the salicylates, antifebrin, or antipyrine. 

Iodide of potassium in full doses (5 to 15 grains) is still recom- 
mended by some authorities. The writer has never seen any benefit 
from the drug in the acute form of the disease, but in the later stages 
it often acts more beneficially after everything else fails. It should be 
given with alkalies. Free iodine has been recommended by some 
authorities. 

Trimethylamine, benzoates, guaiacum, rhus toxicodendron; propyla- 
mine, lithium salts, bromides, colchicum, sulphur, nitrate of potassium, 
and many other agents have been used from time to time, but their 
use is or should be confined to those rare cases where the previously- 
mentioned remedies have failed. 

Opium, however, deserves some mention. At one time it was used 
alone as a method of treating acute rheumatism through all its stages 
and the writer has seen it used in 1 grain doses every four or six hours 
to cut short the disease and relieve pain. It certainly appears to be 
most useful when cardiac complications arise and when pain and car- 
diac distress are present. At any period of the disease opiates may be 
used to relieve pain and induce sleep without interfering with the 
action of other remedies. The combination of opium with full doses 
of nitre (30 grains) often gave excellent results in pre-salicylate 
days. 

Mercury and leeching are seldom resorted to. 

Blisters are recommended by Dr. Harkin in the treatment of acute 
rheumatism upon totally different lines from those laid down by Her- 
bert Davies, who applied them to the affected joints. In carrying out 
Dr. Harkin's treatment one large blister is applied over the cardiac 
area as soon as the symptoms of the case warrant a positive diagnosis 



RHEUMATISM, CHRONIC. 753 

of acute rheumatism being made. The writer has seen many cases of 
the disease treated in this way and has had the privilege of seeing the 
immediate effects of the treatment in several of the patients whose 
cases have been published by Dr. Harkin. In almost all the cases 
there was a most rapid and remarkable relief of all the symptoms, 
pain in the affected joints sometimes disappearing entirely along with 
swelling and local and general high temperature. In some cases no 
return of the symptoms occurs and an uninterrupted recovery ensues. 
In others the pains and fever, though lessened, continue, and salicy- 
lates with alkalies have to be resorted to. 

AYet packs, hot packs, hot baths, and Turkish baths have been 
employed as agents in the treatment of acute rheumatism, but their 
use requires much discrimination. As a rule their routine adminis- 
tration should be discouraged, or confined to the later stages, or to 
sub-acute or chronic attacks. The cold pack, by frequent renewing 
may be used as a substitute for the cold bath in the condition of 
hyperpyrexia, and the hot pack, if used as a local agent, when applied 
to the swollen joints, is of the greatest service sometimes in relieving 
pain and swelling. 

Local treatment is of considerable importance, and though men- 
tioned last, it should be seen to from the beginning of the attack. 
The innumerable lotions, liniments, counter-irritating and anodyne 
applications, as a rule, should be discarded, and the plan of simply 
enveloping the affected joints with dry, absorbent cotton wool, held in 
situ, by loose, open-texture bandages, is by far. the best. It is a great 
mistake to cover the wool with oiled silk or other impervious dressing, 
owing to the irritating nature of the cutaneous secretion. It should, 
for this reason, be frequently changed, and Mitchell Bruce recom- 
mends that the part should be sponged over with a warm solution of 
bicarbonate of sodium before applying wool. Laudanum, chloroform, 
belladonna, solution of salicylates, or the oil of wintergreen, or tinc- 
ture of iodine have been recommended. 

The most thorough and complete rest of the affected limbs is essential 
and sometimes a temporary splint is useful. 

Davies' plan of blistering the affected joints has been already referred 
to. A narrow blister, encircling three- fourths of the joint, often affords 
most marked relief, but since the success of the salicylic or antifebrin 
treatment in relieving pain, it is seldom called for. 

RHEUMATISM, Chronic. 

The treatment of this affection appears to be in as unsatisfactory a 
condition as its pathology. 

Totally different affections are included by many writers under the 
term chronic rheumatism. Confining the present remarks to those 
cases of joint trouble where the clinical history, symptoms, and physical 
signs indicate an arthritic affection, allied to acute rheumatism, the 



754 RHEUMATISM, CHRONIC. 

treatment will depend upon the severity of the case and the stage at 
which it comes under observation. 

Constitutional measures are essential in all instances, and when the 
attack has followed upon acute rheumatism, the remedies which afford 
relief in that affection may be indicated. Thus, the wearying joint 
pains may be often relieved by salicylates and alkalies, especially in 
those not uncommon cases where sub-acute attacks supervene upon 
very chronic joint ailments. 

In treating chronic joint affections of obscure origin, sometimes one 
can clear up the diagnosis of rheumatism after observing the marked 
relief afforded by a few doses of the salicylates. Such relief to pain is, 
however, at the best, transitory. Attention should be paid to the 
general health, and any error corrected. Thus, damp and cold must 
be avoided ; either element is bad, but when both are combined, the 
disease resists all treatment. Variations of temperature must be 
guarded against, and when the patient's means will permit of his 
removal to a warm and equable climate, he should be encouraged to 
try the change. His diet should be selected upon the principle men- 
tioned under the head of Rheumatic Arthritis. Fats are especially 
indicated. 

The various mineral waters as those of Bath, Wiesbaden, Baden- 
Baden, Buxton, Aix-les-Bains, Aix la-Chapelle, Strathpeffer, and Con- 
trexville are indicated. 

Any system of treatment which stimulates the excretory organs and 
facilitates the removal, of waste products does good. Hence, some 
authorities advise the long-continued use of the salicylate of sodium, 
with the view of eliminating uric acid and allied products. Ziemssen 
gives 75 grains daily in one dose. 

Bicarbonates of sodium and potassium and the lithium salts are recom- 
mended upon similar grounds. The best routine treatment for most 
cases is the iodide of sodium combined with alkalies, but it must be 
continued for a long time, and one 30 grain dose of the salicylate of 
sodium may be given at bed-time. This treatment gives good results in 
those cases, showing abundant deposits of urates in the urine. The 
following is a satisfactory combination : 



Be . — Sodii iodidi . 
Sodii bicarb. 
Potassii bicarb. 
Liq. potass, arsenit. 
Decocti sarsap. comp 
S. — A small tablespoonful in a claret-glassfu 
three times a day, after meals. 



• • 3ij- 
• 3iv- 

. 3jss. 
ad g xx.— M. 
of effervescing potash water 



This treatment may be alternated every month with fair doses of 
cod-liver oil and tincture of iron, or quinine. 

Sulphur is a drug of unquestionable utility in many cases. The 



RHEUMATISM, CHRONIC. 755 

compound sulphur lozenges of Garrod may be freely used, but the 
writer obtains the best results by combining its local use (page 750) 
with its internal administration. It may, moreover, be used locally, 
while alkalies and iodides are being employed internally. A good plan 
is to give one large dose, a heaped up teaspoonful, mixed up in orange 
marmalade along with breakfast every morning. 

Ichthyol in 5 to 10 grain doses acts probably by means of its sulphur, 
and the onion is also valuable, if freely used as an article of food, for 
the same reason. 

Guaiacum has long enjoyed a reputation as a remedy for chronic 
articular rheumatism, and is one of the chief ingredients in the electuary 
known as the " Chelsea Pensioner," the other constituents being nitre, 
sulphur, rhubarb, mustard, and treacle. In some cases it seems to 
relieve the joint pains. 

Benzoates, salol, colchicum, or phosphorus may be tried where the 
alkaline remedies cannot be well tolerated. 

The local treatment is of great importance in some cases, and the 
practice of insisting upon absolute rest for the relief of the pain in the 
chronic forms of articular rheumatism has been sadly abused. Many 
of the worst cases have become so from the prolonged rest to the affected 
joint, and the first step in treatment in such cases is to begin passive 
movement. Frastour insists upon the importance of this, even though 
the movement gives considerable pain. It gives better results, if adhe- 
sions have not already formed, though the writer has seen success follow 
where there were extensive adhesions. Passive motion is preferable in 
most cases to Ling's plan of resisting the voluntary efforts of the patient 
at flexing or extending the limb, though this is very useful in the later 
stages. A good plan is to begin the movements while the patient is in 
a hot or warm bath, and this plan is very suitable in cases where the 
patient finds himself able to exercise the affected joints while lying in 
the bath. 

Massage, combined with the passive or active motion, is of the 
greatest use, and various local remedies may be used at the same 
time. 

Baths of various kinds have achieved great reputation in the treat- 
ment of chronic rheumatism, and, as these are carried out at the 
various mineral water resorts in conjunction with the administration 
of the different thermal, alkaline, or sulphur waters, much good may 
be expected from them. Bath and Buxton give excellent results, and 
the Droitwich brine baths, accompanied with massage and passive 
movement, sometimes restores to usefulness joints which have been 
crippled for years. The Turkish bath may be used by those who 
cannot travel, and free movement of the joint, with massage of the 
limb, may be employed in the bath. Where the state of the patient's 
heart contra-indicates the Turkish bath, the Kussian or hot vapor bath, 
or the hot pack, with local sprays, may be safely employed. After 



756 

coming out of the hot wet pack the patient should have a dry pack by 
being enveloped in a number of dry, hot blankets. 

Sulphur baths may be useful, but the amount of sulphur contained 
in even the strongest thermal baths, as at Bareges, Aachen, Aix, etc., 
is, after all, too trifling to exert any marked therapeutic action. The 
temperature of the bath is an important factor in such cases. 

Mud, pine, sand,_and other baths are sometimes used with advan- 
tage. The mud baths of Kisch, Dax, and Marienbad are the best. 

Electricity is of undoubted vaUie in most cases if properly used. A 
weak continuous current passed through the affected joint is of more 
value than a strong current administered for a shorter period. The 
electrodes should be well moistened with hot salt and water. This 
treatment can be carried out in conjunction with any of these already 
mentioned, under it the wearying pains subside, thickening and exu- 
dation diminish, and the nutrition of the affected limb improves. 
Where there is much muscular wasting the faradic current may be 
used. 

Of local applications, counter-irritants, anodynes, absorbents, etc., 
there is practically no end. The best' of all topical remedies in chronic 
articular rheumatism has been, in the experience of the writer, the 
B. P. linimeutum potassii iodidi cum sapone. 

This should be rubbed in twice a day, the joint being at the same 
time exercised, and massage of the surrounding tissues accomplished, 
after which a light flannel bandage should be applied, over which in 
cold weather a piece of chamois may be habitually worn. 

Sulphur appears to come next in value to this, and the writer has 
used these local applications every alternate two or three months. 
The sulphur should be rubbed dry into the skin over the affected joint 
and neighborhood, and covered with a thin layer of absorbent cotton- 
wool, kept in its place by a light bandage. There is no doubt that 
absorption of a small amount of the sulphur does take place, the 
remedy may be given internally with advantage at the same time. 

Alkaline compresses, salicylates, rhus, ammonium chloride, arnica, 
and various other drugs have been recommended, chiefly in the form 
of watery solutions or local wet packs, but little benefit is to be hoped 
from such. Dry warmth, when possible, is better for the affected 
joints than any aqueous solutions. 

Anodynes as chloroform, belladonna, aconite, veratrine, menthol, or 
other local analgesics may be tried in the form of strong spirituous or 
oily applications or ointments. The friction with which they are usu- 
ally applied is generally the most beneficial factor. 

Oleates of mercury, morphine, and cocaine may be used in the same 
way. 

Any form of counter-irritant may be employed from the various 
blistering preparations of cantharides to the mild stimulating com- 
pounds containing camphor ; paraffin oil and turpentine are often 
used. As a rule, benefit is to be expected in proportion to the amount 



RHEUMATISM, GONORRHEAL. 757 

of friction employed. Iodine in the form of liniment is useful where 
the pain prevents friction and massage. It may be applied freely 
until an effect approaching vesication is produced. 

The oils of wiutergreen, cajuput, peppermint, chaulmoogra, and 
cloves may be employed sometimes with advantage. 

Acupuncture and the actual cautery have been tried. 

The clothing of the patient should be carefully seen to, and here 
there is a very great difficulty. The writer has satisfied himself that 
over- clothing is positively injurious, and in some cases would seem to 
be the cause of the joint affection. When the patient is over-clad con- 
tinually, the heat-forming mechanism is, to some extent, in abeyance, 
and when by any chance a chilling of the surface of the body does 
occur the heat centres do not appear to respond sufficiently quickly. 
What is true in a general sense is also true in the case of local chills, 
and a joint or limb which is habitually swathed in woollen fabrics is 
much more liable to be affected by cold in the temporary absence of 
the usual excessive clothing. Dry woollen or flannel inner garments 
of open texture, and of the requisite lightness to ensure thorough venti- 
lation and excape of the perspiration, and at the same time protect the 
surface of the body from variations in temperature meet every require- 
ment. It is an excellent plan to have pieces of wash-leather, sewed 
inside the flannel under- garments, where these cover joints or promi- 
nences of bone. In this way permanent relief may be given to chronic 
rheumatism and rhematoid arthritis of the shoulder, elbow, knee, and 
acromio-clavicular joints.. 

RHEUMATISM, Gonorrhceal. 

Drugs have little effect upon this troublesome complaint. In the 
acute articular form of the disease the first question to settle is the 
treatment of the gonorrhoea. The best plan to pursue is to cease any 
strong astringent or caustic injections, and to begin with a very weak 
solution of the permanganate of potassium in warm water (1 grain to 
4 ounces). This may be injected every hour alternately with plain 
warm water. When pain and fever run high, the ordinary remedies 
for acute rheumatism may be tried in turn, beginning with salicylic 
acid or the soda salt, and when these fail, as they generally do, the 
following may be tried in their order : antipyrine, antifebrin, salol, 
phenacetin, exalgine, oil of wintergreen, and quinine. The last drug 
in large doses gives, perhaps, the most reliable results, when the above- 
mentioned remedies fail ; alkalies (see Acute Rheumatism, page 751) 
should be combined with it or given alternately. Eight grains of 
quinine may be given dissolved in hydrobromic acid, or 6 grains of 
the hydrobromate of quinine may be administered every four, six, or 
eight hours. 

The following formula may be given : 



758 RHEUMATISM, MUSCULAR 

R. 



-Quininse sulpk. . 


• • • 3h 


Acid, liydrobrom. dil. . 


. 3iv. 


Tinct. cimicifugse .... 


• 3XJ. 


Tinct. aurantii amar. . 


. giv. 


Aquae dest 


• ad gvj.- 



-M. 

S. — One tablespoonful four times a day, after meals, in a little water. 

In the chronic form of the disease, iodide of potassium and alkalies 
may be given in full doses, but their effects are at the best most 
uncertain. Quinine, and large doses of the tincture of iron, sometimes 
succeed when other remedies fail. A large mercurial purge — i.e., 8 
grains of calomel followed by a dose of Epsom salt — sometimes relieves 
pain and diminishes fever. 

A mild mercurial course may be tried in very chronic cases. Abso- 
lute rest and all the precautions necessary in acute rheumatism must 
be resorted to in severe cases. 

Local treatment will consist in the use of anodynes or counter-irri- 
tants, according to the acuteness of the pain. Hot fomentations or 
warm poultices smeared over with the extract of belladonna may be 
tried. The various anodyne applications mentioned under Chronic 
Rheumatism, page 756, may be used. The best of these is a linimeut 
composed of equal parts of chloroform and belladonna liniment and 
aconite tincture. Splints may be necessary to secure complete immo- 
bility of the limb. 

As a rule, a fly blister made to encircle the affected joint will give 
more relief than any other application, and in very chronic cases this 
may be applied often. Passive or active movements, massage, friction, 
and the various remedies recommended on page 756 may be resorted 
to. Electricity sometimes does great good, 

Hot baths are to be tried, and the writer has seen good results from 
the spirit lamp bath, and fumigation of the limb with the vapour of 
of calomel, or strapping it over Scott's dressing. 

RHEUMATISM, Muscular. 

At the very early stages a few large doses of salicylate of sodium 
may cut short the disease with rapidity. A very hot bath (106° F.) 
or the Turkish or Russian bath may be given, but, as a rule, dry heat 
is best. Where a hot water bath only is available, it should be fol- 
lowed by a dry hot pack for an hour or more. This often suffices to 
relieve lumbago and torticollis. Where the pain is not speedily 
relieved by these measures, a hypodermic injection of J grain of 
morphine should be given. The various anodyne applications already 
mentioned may be tried, and chloroform and belladonna liniments 
in equal amounts may be applied upon lint and covered with oiled 
silk, over which a large pad of cotton wool is to be kept in place by a 
flannel roller. Hot fomentations, poultices, and dry cupping may 



RICKETS. 759 

be tried, and a smart saline purge, followed by the alkaline treat- 
ment described under Acute Rheumatism, generally succeeds in giving 
relief. 

The continuous current not infrequently fails, but sometimes it acts 
like a charm. Puncture of the affected muscles by a large needle 
driven deeply into the tissues often gives speedy relief. 

In chronic cases the remedies mentioned under Chronic Rheumatism 
must be resorted to, the iodide of potassium three times a day, with 
one large dose of salicylate of sodium at night, being the best routine 
treatment when given in combination with the Turkish bath, dry or 
wet hot packing. 

RICKETS. 

Each authority in speaking of the treatment of rickets emphasizes 
the necessity for correcting some particular error by which, in his 
opinion, the disease has originated. 

As we cannot be said to have sufficient evidence to prove upon what 
error of diet or environment this condition depends, it is the duty of 
the physician to minutely investigate every detail of feeding and every- 
thing connected with the sanitary surroundings of the child, and to 
have any violation of the laws of health promptly rectified. 

Some debilitating influence operating upon the mother during preg- 
nancy, or during the period of lactation, may be the cause of the mal- 
nutrition in the infant, and this consideration shows the very obvious 
importance of preventive treatment. 

A very poor lacteal secretion may be the cause of rickets, and when 
such is evident the child should be weaned or have a healthy wet nurse. 
Much more frequently, however, it would appear that a too rigid ad- 
herence to some one particular artificial food may be the cause, and a 
change in this direction may be imperatively necessary. The physi- 
cian must bear in mind the sometimes marked peculiarities which exist 
in young children, and any hard and fast lines for feeding must be 
considerably relaxed. One infant will thrive upon the milk of a cow 
which will be poison to another and apparently a stronger child. 
Patience and discrimination in this matter are, therefore, of the greatest 
importance at the very outset. 

As a rule, it may be safely laid down that the most easily digestible 
food will give the best results, and there are good grounds for believing 
that an abundance of animal fat is necessary in this form of mal- 
nutrition. 

With older children, and indeed in most cases of rickets, even in 
infants, cream may be freely given. Butter and yolk of egg are also 
valuable. The writer has frequently satisfied himself of the good 
results of beef-juice, raw meat, and soups. The more varied the food 
the better, provided it can be digested. A good mutton broth, with 
the excess of fat removed and all the vegetables carefully strained out 



760 RICKETS. 

by passing it through a fine sieve, is the best compound for the chil- 
dren of the poor. Much has been written against farinaceous or starchy 
foods which is probably incorrect ; nevertheless, they should be used 
sparingly. Exclusive feeding upon these substances must be con- 
demned, and the younger the child the more serious does such a mis- 
take become. 

The food upon which the cow is being fed which supplies the milk 
is of vital importance, and it is the point which is generally overlooked. 
The practice of feeding cows upon the distillery refuse so freely used 
for this purpose in large cities is a serious matter, especially when we 
find that this form of food is often in a stage of incipient putrefaction, 
and it is sometimes unscrupulously used to the exclusion of sound fod- 
der in order to increase the yield of milk. 

Plenty of sunshine and pure air are essential to the patient, as they 
are necessary also to the nursing mother or to the animal supplying 
the milk for consumption by the rickety child. Cold and damp are to 
be avoided. 

Cheadle maintains that the food of a child suffering from rickets 
should contain an amount of animal fat equal to at least one-fourth of 
the total solids, proteids about one-third, the carbohydrates a little 
over one- third, and the salts about one tenth, and that such a diet will 
cure rickets without medicine. 

Muskett, who has recently drawn the attention of the profession to 
the appearance of rickets in Australia, finds the same causes at work 
as in the old centres of civilization. He lays great stress upon the 
necessity of a raw- meat diet, with cream. He advises a child ten 
months old to get 2 ounces raw meat pulp daily, fresh boiled milk di- 
luted with barley water, and entire wheat flour, as recommended by 
Cheadle. 

In some cases peptonizing the milk or food will be found useful. 
Vegetables are essential for older children, but unripe fruits are very 
injurious. • 

Warm clothing and occasional bathing must be insisted upon. A 
warm salt-water bath, in which sea-weed has been infused, may be used 
with advantage in the absence of acute symptoms. It is necessary to 
see that the child be not permitted to kick or push off his bed-clothes 
at night. 

The question of the amount of exercise to be permitted is a difficult 
one, and the physician must be guided by the amount of bone deformity. 
Perhaps it is correct to state that mistakes are too often made by com- 
pelling children to remain in the horizontal position for long periods, 
to the detriment of their general health. The influence of the weight 
of the body in increasing the deformity may be easily exaggerated. It 
may be wiser to enforce rest more rigidly in the case of female children, 
with the view of guarding against pelvic narrowing. 

The vast majority of cases of rickets recover without leaving any 
appreciable deformity, and this fact should be borne in mind in the 



RICKETS. 761 

management of mild cases. Well-padded, soft splints may be used 
where there is much bending of the legs. 

Many drugs have been recommended in rickets about the utility of 
which very adverse opinions are held. There is one, however, about 
which all observers are agreed. Cod liver oil is undoubtedly of the 
greatest value and may be given freely, provided it does not interfere 
with appetite and digestion. In bad cases, associated with much wast- 
ing, the oil should be used externally as well, and too much cannot be 
said for the method of using the abdominal roller with friction and 
cod-liver oil, as already described upon page 507. 

Tonics (iron especially) are useful in most cases, and the syrupus 
ferri phosphatis compositus (Parrish) is the most popular of all these 
drugs. Various other syrups containing calcium are largely prescribed, 
but it is held by many to be exceedingly doubtful that lime is of any 
use in this disease. The large doses of the lactophosphate often recom- 
mended must be sometimes injurious. Large quantities of lime salts 
are thrown out of the body in rickets, but it is hardly possible that the 
phosphate administered can take their place in the system. Though it 
does not act as a restorative, it may exert some influence on nutrition 
by its action upon the nerve-centres. 

Phosphates of iron and calcium and phosphoric acid are often given 
upon the supposition that they supply phosphorus to the affected bones. 
This is, of course, a mistake. These bodies remain as phosphates in 
the blood, and do not exert any of the marked effects of phosphorus 
when given in the free form. 

Free phosphorus has of late years been much used in the treatment 
of rickets, and there cannot be any question of its marked effects upon 
the growth of the bone. 

Wegner demonstrated that small quantities of free phosphorus 
stimulated and altered the growth of bone when given to healthy 
animals, so that the cancellated structure became hard, compact bone ; 
and in the case of fowls the shafts of the long bones became solid 
cylinders of dense osseous tissue. Kassowitz found that when given 
in rickets, even of the most advanced type, speedy recovery always 
resulted, the bones becoming hard in four week in most cases. 

Numerous observers, among whom are Hartwitz, Jacobi, Friese, and 
Montmolli have confirmed these very striking results. He advises 
that the drug should be given dissolved in cod-liver oil (1 : 10,000). 
Hazard's solution as devised by Thompson consists of the following : 

r£. — Phosphorus .... 1 grain (or 0.0648 grammes.) 

Absolute alcohol . . . 350 minims (20.65 c. c.) 

Glycerin 2 ounces (56.79 c. c.) 

Spt. of peppermint . . . 10 minims (.59 c. c.) 

Five minims of this solution may be given to a child three years old. 
Double this dose in the opinion of Berg should not be given, and the 

49 



762 rigor. • 

danger of inducing degeneration of the liver-cells must not be for- 
gotten. 

* (Dembitz uses the following solution in half-drachm doses twice daily. 
It may be given in conjunction with cod-liver oil after meals. 

B • — Phosphor! gr. \ -. 

Carbon, bisulph gtt. vj. 

Aquse dest. ........ ^ iv. — M. 

The B. C. P. formula is a valuable one: Phosphorus 11 grains, 
chloroform 2 i drachms, ethylic alcohol, 12$ drachms.. Dose for a 
child three years old — 1 minim. The writer, however, prefers the fol- 
lowing simple formula to all others : 

R.— Olei phosphorati (U. S. P.) TTlxl. 

Olei morrhuae ad jfvj — M. 

S. — One teaspoonful for a child one year old, to be given after food, along with 
an equal quantity of fresh cream. 

The writer's experience of the phosphorus treatment of rickets is too 
limited to make an expression of opinion from him of any value, but 
while he has no doubt of its great efficacy in cutting short the disease, he 
thinks it may possibly be found to be open to serious objection. Con- 
sidering the experimental results of Wegner, who has demonstrated 
the condensation and hardening produced in bone by its use, and 
remembering that the great majority of cases of rickets recover upon 
improved diet and cod-liver oil, without leaving any permanent defor- 
mity, it does not seem possible that phosphorus might determine the 
setting of the bones permanently in their deformed condition. This 
conclusion is, however, based upon theoretical considerations, and it is 
not arrived at by clinical experience, but its importance, if it be found 
to be correct, can hardly be exaggerated. 

The local treatment, after the subsidence of acute symptoms, will 
consist in the cautious use of massage and galvanism. Intestinal and 
pulmonary catarrhs should receive early and prompt attention when 
they arise. The treatment of the permanent deformities is to be car- 
ried out upon general surgical principles by osteotomy, osteoclasis, or 
excision, or by suitable mechanical appliances. 

RIGOR. 

Though no treatment will be of any use unless it succeed in combat- 
ing the cause of the rigor, nevertheless the condition of the patient can 
be made much more endurable by a few simple measures. 

Following up the natural instinct of the patient, who generally has 
a marked desire to get as near to the fire or any convenient source of 
heat as possible, the physician should insist that he take immediately 
to his bed, where he may be surrounded by dry warm blankets, hot 



KODENT ULCER. 763 

water bottles, and excess of clothing. Stimulants may be freely given. 
One full dose of brandy or whiskey should be administered as soon as 
possible. It is advisable to give this with some very hot water and a 
little sugar. When the heat has been brought to the surface of the 
body the excessive clothing may be gradually removed. 

Of drugs, nitrite of amyl and chloroform sometimes markedly cut 
short the attack ; but, upon the whole, it is advisable to maintain a 
position of neutrality, and await further symptoms. Quinine often 
prevents or modifies the severity of recurring attacks ; but, owing to 
its slowness of action, it has no effect whatever upon the rigor if ad- 
ministered during its presence. It is of most value in the rigors of 
pyaemia. The newer antipyretics do not give any more satisfactory 
results. The old-fashioned plan of giving a speedy emetic at the very 
outset, when this is feasible, sometimes appears to modify the severity 
and duration of the rigors which usher in acute inflammatory or 
zymotic affections. When there is much constitutional excitement or 
apprehension on the part of the patient, a hypodermic injection of 
morphine often is of great benefit. It should, however, be used with 
caution if renal disease is marked. In the rigors following the use of 
the catheter, if given immediately upon the first feeling of chilliness, 
the rigor may be prevented. 

RINGWORM— See Tinea. 
RODENT ULCER. 

The treatment of this obstinate affection should be that indicated 
for epithelioma. Constitutional remedies are worthless, and removal 
of the ulcer affords the only means of checking or curing the disease. 
Where circumstances permit, complete excision by the knife is, upon 
the whole, the most satisfactory. Sometimes, however, the situation of 
the ulcer renders a cutting operation difficult and incomplete, and 
sometimes the patient will submit to the destruction of the growth by 
means of caustics, when the use of the knife will not be permitted. A. 
third method, which gives the best results in large ulcers, is available 
by combining the knife and caustics, and by this combined plan of 
operation extensive and deep ulcers may be permanently destroyed, 
which otherwise would be beyond the reach of surgery. 

In the use of the knife it is necessary to go wide of the ulcer, leav- 
ing a perfectly healthy floor and margins. 

Where caustics are to be used, the operator has the choice of chloride 
of zinc, Vienna paste, potassa fusa, London paste, arsenic, nitric acid, 
the acid nitrate of mercury, etc. 

The most satisfactory of these is the first mentioned. By attention 
to details the limits and depth of its destructive action may be counted 
upon with comparative certainty. The writer has used it many times 
in the treatment of this affection occuring in the practice of the late 
Professor Gordon, and always without any mishap, even when the 



764 ROSEOLA — RUPIA. 

ulcer had crept into the orbit. The chloride may be mixed with three 
parts of wheaten flour, and in this condition it may be spread dry in 
an even layer upon the ulcer. If the surface to be destroyed is not a 
freely secreting one, the powder may be made into a stiff paste with 
water, and spread in a layer as thick as a half-sovereign. The sur- 
rounding tissues may be preserved by means of plaster-of-Paris, but 
this is seldom necessary. The paste may be left in situ, but about the 
face it is better to remove it in two or three hours, and re-apply it 
again as soon as the slough has separated. In this way the depth of 
its destructive action can be regulated almost with the precision 
obtainable by the use of the knife. 

In the destruction or extirpation of deep and wide ulcers by the 
knife, if the hollow bones of the face or orbital cavity have been in- 
vaded, the combined method is the only one available, the zinc paste 
being carefully applied to the recesses of the knife wound. In some 
cases the actual cautery, the thermo- or galvano- cautery, may be used. 
Occasionally in the early stages of rodent ulcer the milder treatment 
applicable to lupus may be successful. The after-treatment of the 
ulcer is to be conducted upon general principles. 

ROSEOLA. 

The treatment of this mild affection may be carried out upon the 
lines indicated under Erythema, page 259. A mild diaphoretic follow- 
ing a saline purgative, and the use of a warm bath containing a little 
alkaline carbonate, and in severe cases the anointing of the skin by a 
bland oil or by lard is all that is generally necessary. 

ROTHELN. 

The treatment applicable to a very mild attack of measles may be 
carried out in most cases of German measles. (See page 489.) The 
patient will require little medication, save the diuretic mixture men- 
tioned upon 490. 

ROUND WORMS— See Ascaris Lumbricoides, page 53. 

RUBEOLA— See Measles, page 489. 

RUPIA. 

The treatment of this affection will simply resolve itself into the 
treatment of the disease of which it is one of the varied manifestations 
— syphilis. There are only two drugs of any known value, and these 
are mercury and iodides. Rupial eruptions, according to Hutchinson, 
usually occur after mercury has been given (in the treatment of 
syphilis) in too large doses, and has disagreed and been wholly laid 
aside for some time. Donovan's solution, internally, may be given, 
and though sometimes in these cases the iodide of potassium or sodium 



SaCRO-ILIAC J0IN"T DISEASE — SCABIES. 765 

may give excellent results, as a rule, mercury will be necessary. When 
this drug is given in rupia the dose should be small, and the adminis- 
tration must be continued for a long period, but the constitutional effects 
of the drug are to be avoided. Sometimes it will be found advisable 
to suspend the mercury for a few weeks, during which large doses of 
the iodide may be tried. Recently the writer saw a most intractable 
case of rupial ulceration which had resisted all treatment in the wards 
of Professor Fournier until he tried the hypodermic injection of dog's 
serum, as recommended by Professor Richet ; most marked improve- 
ment rapidly set in. The general health of the patient is a matter of 
vital importance, and the diet must be of the best possible. Change 
of scene, and, if feasible, an ocean voyage may be desirable. 

Locally, little need be done in most cases, as the crusts fall off after 
the ulceration heals under the influence of the mercurial iodide course, 
and it not advisable to disturb the crusts or interfere with them in any 
way. 

Where ulcerated surfaces are found, in spite of this treatment, an 
ointment of iodoform will be the best dressing. The fumigation 
bath with* the vapor of sublimed calomel sometimes acts like a charm. 

RUPTURE— See Hernia 

SACRO-ILIAC JOINT DISEASE. 

The treatment will be based upon the general principles laid down 
for knee-joint and hip-joint affection upon pages 429 and 364. Thus, 
absolute rest to the affected surfaces must be rigidly maintained for a 
long period. Abscesses should be opened as soon as their presence 
is demonstrated, and after these fail to heal, all sinuses may be opened 
up and any diseased bone removed. The constitutional remedies and 
general directions as to diet, environment, etc., apply to this affection. 

SARCINiE. 

The treatment of these microscopic fungi simply resolves itself into 
the management of the primary gastric affection, which is fully dealt 
with under the headings of dyspepsia and cancer of the stomach. 

SCABIES. 

The use of almost any one of the innumerable parasiticides will kill 
the acarus and its ova, but the most harmless to the patient, and the 
one most certain and cleanly in its action, is sulphur when properly 
used. The speediest cure is Vleminckx's solution, by means of which 
a smart attack of itch may sometimes be removed in a few hours. 
This solution is prepared by boiling lime or lime putty with sulphur 
in a large quantity of water, and after the sediment subsides a bril- 
liant, clear yellow solution remains, which is the remedy under con- 
sideration. 



766 SCABIES. 

The proportions of the ingredients are of little matter as it is well to 
have them in excess, and the water will only dissolve a small amount 
of the penta-sulphide of calcium. Two ounces of sublimed sulphur, 
and 1 ounce of slaked lime will make a gallon of the fluid, and with 
this a large school of children affected with scabies may be cured in a 
few hours. All that is necessary is to take a small sponge and swab 
the solution freely into the skin. As the liquid comes into contact 
with the organic matter contained in the secretions of the skin it gives 
off free sulphuretted hydrogen, and leaves a fine powdery residue, 
filling up the furrows on the cutaneous surface. A previous hot bath, 
with soft soap scrubbing is not necessary, and hence sometimes little 
irritation is caused by the remedy, but when there is already much 
traumatic eczema present, and where the liquid is rubbed in or applied 
frequently, it may produce considerable irritation. 

Immediately after its use the patient may put on his clothes, when 
the excess of the liquid will cause destruction to any wandering male 
or young female insects adhering to them. 

It is well to make several applications to insure complete destruc- 
tion to any young which may have escaped the action of the liquid, 
owing to their deep position in the burrows. 

Powdered or sublimed sulphur may also be applied in its dry state, 
and well rubbed into the skin and sprinkled over the inner surface of 
the flannel or woven under-garments. It can be rubbed into the 
hands and between the fingers, after which a leather glove may be 
worn. This method, which is cleanly is not at all so efficacious as the 
solution. 

The oldest, and, perhaps, the surest of all methods of using sulphur 
for the treatment of scabies is to give the patient a good hot bath, in 
which the body is to be thoroughly scrubbed with a hair brush and 
soft soap, so as to open up the burrows of the itch insect, after which 
sulphur ointment (1 : 5) is to be rubbed in for several minutes with 
the palms of the hands into every part of the cutaneous surface, except 
the face and scalp. 

This can be best done before going to bed, the patient sleeping in a 
combination dress. In the army, after the bath, scrubbing, and rub- 
bing in the ointment, a blanket, smeared over with the ointment, used 
to be wrapped around the patient's body. 

The U. S. P. ointment is quite too strong, and will give rise to 
severe irritation if applied for several nights in succession. After the 
usual bath and scrubbing, a weaker preparation (1 : 12) will answer 
all purposes if the applications are kept up, but it is well to begin with 
the official ointment. The writer has not used the ointment for the 
last fifteen years, and has never seen a case which did not yield to the 
solution after a few applications. It is a good thing to give the clothes 
a short baking in an even or disinfecting chamber. It is said to kill 
the ova, but these probably never get upon the clothing. 

The innumerable formulae, containing Peruvian balsam, storax, tar, 



SCARLATINA. 767 

paraffin oil, copaiba, stavesacre, green soap, cocculus indicus, creasote, 
phosphorus, oils of cade, cajuput, anise, etc., should be banished from 
our text-books. 

After the destruction of the insect it may be necessary to treat the 
eczema and irritation, partly the result of the parasite, and partly the 
result of the remedy ; some bland unirritating ointment, lard, or oil, 
easily accomplishes this. 

SCALDS— See under Burns, page 95. 

SCARLATINA. 

Under the head • of Measles, upon page 489, the diet, selection of a 
sick room, and other details of importance are mentioned, which are 
equally applicable to scarlatina, and need not be here mentioned. 
Owing to the highly infectious nature of this disease the sick-room 
should be as isolated as possible, and a sheet dipped in carbolic lotion 
(1 : 100) should be fastened outside the door with the view of cutting 
the room off completely from the rest of the house. This will also 
keep the air of the sick chamber quite sweet. Relief may be obtained 
by sponging over the body with a soft sponge and warm water, only a 
small portion of the surface being exposed at one time. 

It is not advisable to permit baths at this stage, especially when the 
rash is ill-developed. At a later period their use is indispensable. 
The bowels should be relieved with a smart saline as early as the case 
comes under observation- 
Numerous drugs and systems of treatment are still recommended 
with the view of cutting short the fever and destroying the microbe 
upon whose presence the disease is believed to depend. 

The writer cannot say that he has found any such specific action in 
any of these agents. Some of them are positively dangerous if given 
in full doses, and, as a broad rule, it is still to some extent true, that 
" scarlatina is dangerous only through the officiousness of the physi- 
cian." 

The writer was tempted once to say that it might be accepted as a 
general truth, to which there were not many exceptions, that a mild 
case of scarlatina needed no medical treatment, while the really 
malignant cases were generally beyond the reach of any treatment. 

Nevertheless, in the management of this disease, its complications 
and sequelae, there is often wide scope for the skilled therapeutist. 

The treatment may be divided into two distinct parts — viz., the 
guiding of the patient through his attack, and the means by which the 
disease may be prevented from spreading to other members of the 
same household. In cases evidently mild from the beginning, the 
preventive treatment is obviously the most important, and this is more 
true of scarlatina than of most other contagious diseases, for the simple 
reason that the mortality falls greatly with the age, and if a child can 



768 SCARLATINA. 

be shielded from infection as long as possible, his attack will probably 
be milder when the inevitable does overtake him in after years. 

The importance of isolation and scrupulous nursing are obvious, 
and it must be pointed out that the popular notion is wrong — that the 
most infectious period is during the later stages of desquamation. The 
disease is undoubtedly very infectious in the early stages when the rash 
and fever are at their height. 

The most valuable preventive of the spread of the disease germs is 
the anointing of the body with a weak carbolic oil (1 : 50). This 
may be commenced from the first, and if such an application fails to 
destroy the germs, it will effectually prevent the spread of the fine 
epithelial dust containing them ; an oil (1 : 25), may be freely used 
afterward when desquamation sets in. The free use of stronger solu- 
tions may possibly endanger the kidneys. Hot baths and scrubbing 
of the skin to remove the dead epithelium, should be resorted to, after 
the subsidence of the fever and throat complications. Oil of eucalyptus 
may be used instead of the carbolic oil, and corrosive sublimate- 
(1 : 4000) has been highly recommended. Its occasional use would be 
unobjectionable. 

In the early stages a mild diaphoretic can do no harm, and for a 
child two or three years old a mixture may be ordered like the 
following : 



R . — Spt. sether. nit 

Liq. ammon. acet 

Potassii citratis ..... 

Syr. simplicis 

Aquse camph. ..... 


• Sij- 

. ^jss. 

. ad £ iv.— M 


S. — A teaspoonful to be taken every third hour. 





In the wards of the Belfast Royal Hospital where this expectant 
method is applied in a routine way, I find that for the ten years ending 
in 1883, only one death occurred, and this patient was moribund upon 
admission, but it would be manifestly unfair to attach too much im- 
portance to these results as only 133 cases were admitted during this 
period. The diet was almost exclusively milk ; nephritis was rare. 

When the fever runs very high, small doses of antipyrine may be 
given, and in adynamic cases, quinine. When hyperpyrexia occurs, 
tepid baths and cold affusion may be tried. The salicylate of sodium 
often acts well as an antipyretic. 

The drugs recommended for the routine treatment of scarlatina are 
very numerous, and statistics are quoted to prove extraordinary value 
of most of them. 

Biniodide of mercury, originally advocated by Dr. Illingworth, and 
maintained by many physicians to be a specific, has been extensively 
employed, and upon the whole, the various reports are favorable. The 
writer's experience is too limited, but he has not any intention of trying 



SCAKLATINA. 769 

it again as a routine remedy ; -j^ grain of the bichloride of mercury may 
be given in a tablespoonful of sweetened water along with 2 grains of 
the iodide of potassium every two or three hours. It is claimed by 
many that this treatment rapidly diminishes fever and prevents des- 
quamation, and limits the period for isolation to between two and three 
weeks in all. 

The bichloride of mercury has been used alone with similar glowing 
results, and gray powder has also been tried. 

Salicylic acid and the soda salt have been extensively used as routine 
remedies. 

Mineral acids, notably the hydrochloric, are harmless agents, and 
appear to be as grateful and beneficial as they are in typhoid and 
typhus fevers, where their routine employment is generally spoken of 
as the Swedish method of treating fevers. 

Oxygen and peroxide of hydrogen — the former as water charged 
with the gas, the latter as the solution prepared by acting upon per- 
oxide of barium by hydrochloric acid — are safe and, according to the 
testimony of many competent observers, valuable remedies in adynamic 
cases. 

Ammonia carbonate in small doses frequently administered has been 
supposed to possess specific action, but there is little to be said in sup- 
port of the drug except in adynamic cases, and then only for a limited 
period is it admissible. 

Oil of eucalyptus, upon the glowing reports of Curgeuven, is attract- 
ing some attention. He gives internally a few drops in water, and 
sprinkles to saturation everything about the patient with it. Extra- 
ordinary success is claimed for the specific action of the remedy. 
The writer has long used it as an anointing oil alone or mixed with 
the carbolic oil, and believes that it is a safe and efficient destroyer of 
the virus as it comes off by the skin, and much more reliable than 
weak carbolic oil. 

Chlorate of potassium is a favorite drug for routine administration, 
especially in cases where the symptoms are very prominent, when it is 
often given in full doses, as well as being at the same time employed 
locally. It should be given with caution, as it has caused or exagger- 
ated nephritic complications, and in large doses it is dangerous. Upon 
the whole, its use should be limited to gargles and sprays in this disease 
where nephritis is a possible or likely sequela. The writer has seen it 
do serious mischief. 

Benzoates of sodium and ammonia have been recommended and used, 
but with somewhat doubtful success. 

Sulphocarbolate of sodium has been much used in the treatment of 
scarlatina, and though the writer does not think it necessary to employ 
it as a routine method of treatment, nevertheless he resorts to it in 
cases of severity of fever or throat symptoms. A child four years old 
may get 2 or 3 grains every three hours. It is valuable in the later 
stages where suppuration of the throat has occurred. 



770 SCIATICA. 

Quinine in some severe cases appears to do well, and if combined 
with iron it meets the requirements of reducing temperature and modi- 
fying the unhealthy action in the throat. Digitalis is used by some 
authorities as the best antipyretic in conjunction with quinine. 

Locally the best routine treatment for the majority of cases is a weak 
carbolic solution sprayed into the throat. The following formula may 
be used with the youngest children : 



R . — Glycerini . 

Pulv. sodii bor. 
Acidi carbolici 
Aquae rosae 



• . - gr. xlv. 
ad ^x.— M. 



Older children may use this as a gargle, diluted with half as much 
water. The glycerin of carbolic acid (1 : 5) may be cautiously applied 
on lint to the tonsils if any membranous exudation appears. 

Gargles containing chlorine, bromine, iodine, corrosive sublimate, 
iodide of mercury, sulphurous acid, permanganate of potassium, sulphur, 
tincture of iron, boroglyceride, chlorate of potassium, and any other anti- 
septic may be used. These may also be employed as sprays. 

Iced compresses, warm poultices, cotton wool under oiled silk, or 
local wet packs, cold or hot according to the relief which they afford, 
may be tried ; and where there is great swelling of the tonsils, steaming 
by holding the head over boiling water under a sheet or tent made in 
the bed may give ease. 

Various opinions are held about the treatment of severe cases where 
the rash fails to come out. The hot pack must be used with great 
caution, especially if the temperature is high in such cases, but the 
administration of a hot bath containing a little mustard may be tried, 
for a few minutes only, with advantage. With a badly developed rash 
and a very high temperature the cold bath, cold affusion, or the cold 
pack may be cautiously employed. 

Pilocarpine hypodermically, aconite, veratrum, and other drugs 
internally, seldom give good results under such circumstances, and 
their use is fraught with danger. Rheumatism, nephritis, and other 
complications are treated upon the lines mentioned under their several 
headings. 

Six weeks is considered a fair average period of isolation, but com- 
plications and tardy desquamation may prolong it to nine. This period 
may be materially shortened by the use of soap, warm baths, and 
scrubbing, and there is little doubt but the free use of the oil of 
eucalyptus may in many cases safely reduce it to one month. 

SCIATICA. 

Under the heading of Neuralgia (pages 521 to 536), all the various 
remedies found useful in sciatica have been fully discussed. They may 
be briefly summed up here for convenience. First, and by far the 



SCLERODERMA. 771 

most successful in the majority of recent cases, is the author's method 
of using morphine by the hypodermic syringe. This may be regarded 
as a combination of acupuncture, aquapuncture, parenchymatous in- 
jection and narcotics (page 523) ; absolute rest, counter-irritation by 
blisters, liniments, actual or thermo-cautery ; drugs, such as salicylates, 
salol, quinine, large doses of iodide of potassium, chloride of ammonium, 
phenacetin, antipyrine, exalgine, cannabis indica, atropine, arsenic, 
iron, phosphorus, cod-liver oil, phosphide of zinc, cimicifuga, gelsemium, 
ergot, nitrate of silver, stramonium, turpentine, benzoate of sodium, the 
relative values of which are referred to under Neuralgia. 

Local anodynes, as chloroform, belladonna liniments, veratrine, 
menthol, conium, atropine, methyl chloride and ether sprays, are, as a 
rule, disappointing ; so are injections of cocaine, antipyrine, theine, ether 
etc. Electricity and galvanism have been already discussed. They are 
sometimes of the greatest value, alone or combined with hydropathy, 
Turkish baths, and massage. In chronic cases the great value of deep 
injections of a 1 per cent, solution of osmic acid, combined with frequent 
punctures, has been already referred to. 

Some cases yield to the local application of sublimed sulphur, cotton 
wool, and bandaging. Where these measures fail the operations of 
nerve-stretching, neurotomy, and neurectomy, as described upon page 
534, may be resorted to. Suspension, as employed in locomotor ataxia, 
may have a trial, and hypnotism has been successfully pressed into the 
service. 

SCLERODERMA. 

The treatment of this condition is in the same highly unsatisfactory 
state as is its pathology. In the absence of any definite knowledge, 
the physician will be safe in paying attention to the general state of the 
patient, and in correcting any abnormal condition or violation of the 
laws of health. 

Tonics, such as arsenic, phosphorus, chloride of gold, nitrate and 
oxide of silver, cod-liver oil, and iron, have occasionally been found of 
use when combined with warm flannel clothing, and abundance of 
pure air and good food. Mercurials are harmful. 

Massage, electricity, Turkish baths, and persistent inunction of the 
body by any animal oil or fat, if carried out with the internal adminis- 
tration of one or more of the above tonics, will give the best results to 
be expected in our present state of knowledge. 

Sclerema neonatorum has been successfully treated by small doses of 
mild mercurials; but the chief hope in such cases will lie in enveloping 
the body in successive layers of cotton wool, and keeping it in a very 
warm or hot room, and artificial feeding by a soft rubber catheter with 
peptonized foods and meat j uice. 



772 SCLEROSIS, DISSEMINATED — SCLEROTITIS. 

SCLEROSIS, Disseminated. 

Little can be accomplished in the treatment of this disease. One 
drag after another has from time to time enjoyed some ephemeral 
reputation as a specific; but, nevertheless, owing to the numerous com- 
plications which may arise during its progress, the physician may, by 
the aid of drugs and by the help of therapeutic measures, be able to 
prolong life and dimmish pain and discomfort. 

Iodide of potassium appears in many cases to have the power of at 
least arresting the development of the disease, and it or the iodide of 
sodium should get the first trial in all cases coming under treatment ; 
but the drug must be given for a long time, and in full doses; 10 to 
15 grains three times a day have appeared to the writer to check the 
progress of the degeneration for a time. 

The next drug from which there is some prospect of benefit is the 
chloride of gold and sodium, and Batholow affirmed that it sometimes 
cures He stated that it had the power of causing absorption of con- 
nective tissues of pathological formation. The dose should be y 1 ^ grain 
in pill twice or three times daily. 

Nitrate of silver appears to act in the same way, but its power of 
causing discoloration of the skin must be remembered. 

Next in order of reputation comes mercury, and some believe that the 
bichloride in small doses, if given early, will arrest the disease. It 
should always be given if there be any reason to suspect the presence 
of a syphilitic taint, and it may be given without any hesitation com- 
bined with the iodide of potassium, omitting it each alternate month, 
while the iodide is continued. 

Arsenic, phosphorus, zinc, and the host of so-called tonics have 
been recommended, and cod-liver oil should always be tried in early 
cases. 

Massage and sulphur baths have been found useful by Bastian in 
the earlier stages. 

Galvanism and electricity are sometimes harmful, though occasion- 
ally they may appear to give temporary benefit. 

Bedsores, bladder troubles, insomia, and other complications are to 
be treated upon general principles, and no means by which the general 
nutrition of the body can be improved is to be neglected. 

SCLEROTITIS. 

As inflammation of the sclerotic is generally secondary to choroiditis 
or iritis, the details of treatment mentioned under these headings should 
be carried out. 

In episcleritis, anodynes, as atropine, instilled into the eye, with a 
paste composed of glycerin and extract of belladonna smeared over the 
brow, and a smart saline purge, followed by full doses of the salicylate 
of sodium, will give relief in most cases. 



SCROFULA. 773 

SCROFULA. 

The treatment of scrofula need not be here entered upon at any 
length. Under the head of Phthisis full particulars are detailed 
regarding improved hygiene, ventilation, clothing, food, occupation, 
residence, drugs, etc. Without here discussing the identity of scrofula 
and tuberculosis, all that is written concerning phthisis may be safely 
applied to scrofula or struma, and hence there is no necessity for repe- 
tition. Under the headings of Joint Diseases, Caries, Ophthalmia, 
Lupus, etc., the various treatments of the 'local manifestations of this 
diathesis are enumerated. It remains to mention the treatment of 
the strumous affection of the lymphatic glands, though even this is 
scarcely necessary, since the remedial measures detailed under the 
heading of Lymphadenitis, upon page 479, embrace nearly everything 
applicable to strumous adenitis. 

Where suppuration has already occurred in the glands, there can 
be little doubt that its evacuation is the only practical solution, and 
this should be carried out in the ways already mentioned, the free 
incision being generally the most satisfactory. A word may be said 
about the most suitable time for incising, and the generally accepted 
rule is to make an opening as soon as fluctuation demonstrates the 
presence of pus. The writer ventures to question the wisdom of such 
a rule when applied to the evacuation of pus from a chronically- 
inflamed strumous gland. 

There is no objection to wait for some time until the matter comes 
nearer to the surface if deep in glands — about the jaw, for example. 
The more complete the suppuration the less likelihood of a return, 
and the less chance of the wound closing up too soon, and hence the 
advantage of a reasonable delay, but, of course, delay until the skin 
itself participates is to be condemned. It is, moreover, not advisable 
to have the contents of a disorganized gland trickling over a fresh 
incised surface of any magnitude when this can be diminished by 
judicious waiting. 

About the face as small a wound as possible should be made, and 
it is a matter of great importance to insure that the incision into the 
capsule of the gland is fully as large as, or larger than, the skin open- 
ing. When very small, a minute drainage-tube or a few strands of 
carbolized tow may be inserted for a time, though this generally gives 
very slow results. 

The greatest difficulty is experienced in the indolent glands which 
do not suppurate. Where constitutional measures, as improved 
dietary, fresh air, prolonged courses of iodine, iodide of iron, cod- 
liver oil, phosphates, arsenic, etc., fail, local measures may be pushed. 

These are mentioned already upon page 478. Counter-irritation by 
iodine applications, as the tincture of the U. S. P., may be persevered 
with. Friction, with the ointment of iodide of lead, or of iodine, or 
the lin. potass, iod. cum sapone (B. P.), gives good results. Where 



774 SCEOFULA. 

the gland occupies a prominent position, suppuration may be encour- 
aged by the injection of irritants, as the tincture of iodine, carbolic 
acid, etc., but this can generally be accomplished by rough friction 
with iodine ointments. Sometimes these injections cause rapid resolu- 
tion without suppuration. The method of Treves (page 480) may be 
tried, and, where all measures fail, the speedy, safe, and generally satis- 
factory method is to excise the gland or glands by the knife. Where 
a portion of a gland only has broken down and suppurated, the writer 
has obtained good results by inserting a small spoon through the origi- 
nal opening and scraping out the cavity. 

Duncan thus sums up his advice about the treatment of strumous 
glands : 

" First, the glands being in the early stage, you apply all those 
internal hygienic remedies which the physicians will point out to you. 
You apply rest by means of a well-padded stock and cuirass. Sup- 
posing it was further advanced, but not suppurated, then I would use 
the injection of iodine, two, three, or four drops injected into each 
gland, according to circumstances. I think the iodine is better than 
the bichloride. I tried ignipuncture by putting in the platinum wire 
through the gland, and threading upon it hollow needles, taking care 
not to heat the hollow needles and hurt the skin. You can then 
destroy large portions by electric heat without making a skin wound. 
I must say that ignipuncture has not been so satisfactory as I should 
have expected, although I have seen cases in which considerable im- 
provement followed, whether because I at the same time put the glands 
at absolute rest or not, I am not quite sure. Suppose the iodine injec- 
tion fail, then opening and scraping, I should add to the scraping 
the injection of parasiticides. I myself use salicylic or boric acid for 
the purpose of destroying the bacilli, whether pyogenic or tubercular. 
And, lastly, in a few and limited number of cases, excision of the 
glands." 

Treves strongly condemns the use of iodine externally. He says it 
is probably in nearly all cases harmful, and he urges the necessity of 
securing absolute rest to the head and neck. He states that scraping 
and cautery puncture are only available for a very limited number of 
cases, and he insists that excision offers the simplest, safest, and most 
certain method of treating this obstinate affection, and expresses his 
opinion : " For no measure which has been employed for the treatment 
of the strumous neck can such excellent results be claimed as attend 
upon the simple excision of the glands. Considering the grave com- 
plications attending the disease, the tedious path it follows, and the 
disfigurement it leaves, it may be permitted to regard this operation as 
not the least of the improvements in modern surgery." 



SCURVY — SEA-SICKNESS. 775 

SCURVY. 

The remedies for this affection are free supplies of vegetables, both 
as preventive and curative agents. The disease has almost dis- 
appeared from observation since the compulsory regulation insisting 
upon ship owners to supply lemon-juice to their sailors. Fresh lemon- 
juice is at once the best prophylactic and the best remedy once the 
disease has become established. It may in this latter case be used 
freely in the presence of diarrhoea and dysentery. Indeed, as a general 
rule, it is useless to attempt the cure of any of the complications of 
scurvy as long as the blood condition remains unremedied. Therefore, 
as soon as the patient is put to bed, no matter what his condition may 
be, fresh lemon-juice diluted with water should be administered every 
hour or two. Lime-juice, and even citric acid, where nothing better 
can be had, may be given. Fresh vegetables of every kind may be 
given — lettuces, salad, fruit, cabbage, mashed potatoes, etc. 

As soon as the condition of the gums permits, solid animal food may 
be used, and underdone roast meat or steak is the best. Strong soups, 
beef juices and essences, or broths containing large quantities of fresh 
vegetable matters strained out just before administration, may be given 
when the state of the mouth prevents mastication. 

Ulcers may be treated with a lotion of lemon-juice. The bleeding 
gums may be improved by vegetable astringents used as mouth washes. 
The following is suitable r 

R. — Tinct. kramerise J;j. 

Tinct. catechu comp ^ ss. 

Decoct, quercus . . . . .ad ^xx. — M. 

Where there is much fetor of the breath, weak chlorine or iodine 
solutions or the permanganate may be employed. Chlorate of potas- 
sium is a favorite local remedy. Alum is, perhaps, the best of all appli- 
cations when mixed with some fresh lemon-juice and water (1:40). 
Nitrate'of silver has been successfully applied to the sloughing gums. 

Internally there is generally no necessity whatever for any drugs, 
but where hemorrhages are extensive and threatening, ergot by the 
mouth or ergotine hypodermically should be resorted to. The astrin- 
gent preparations of iron and the tincture of larch bark give good 
results. 

Excessive salivation may be checked by atropine. 

Massage and tonics, like quinine, iron, and arsenic, are indicated 
during convalescence, and hydropathy hastens recovery. 

The danger of a fatal syncope when the patient assumes the erect 
position in bad cases must never be forgotten. 

SEA-SICKNESS. 

The usual advice of recommending a hearty meal before going on 
board is a mistake, and fasting is also to be avoided. A light meal at 



776 SEA-SICKNESS. 

least three hours before experiencing the ship's motion will put the 
patient in the best condition for struggling against this distressing 
malady. Of prophylactics there are hosts recommended, but few are 
of the least use to patients susceptible to sea-sickness. The best remedy, 
and one which undoubtedly often succeeds to preventing the attack, is 
the bromide of ammonium, sodium, or potassium. The first-mentioned 
is the most reliable. It should be given in 20-grain doses for a day or 
two before embarking. As soon as a susceptible patient gets aboard, 
he should lie down flat upon his back with his head low, and his eyes 
closed. A light abdominal binder, or pressure applied to the epigas- 
trium is useful in many cases. The general advice given is to keep 
walking about upon deck is very good to travellers not markedly sus- 
ceptible, and many such undoubtedly escape sickness in this way, but 
the very sensitive are sure to succumb if they adhere to it. One dose 
of chloral (20 grains), with the bromide may be tried when the voyage 
begins at night. 

Chapman recommends ice to the spine, but its inconvenience is a 
barrier to its extensive trial. 

Morphine, opium, cannabis indica, cocaine, chloroform, caffeine, atro- 
pine, alcohol, and nitrite of amyl have been recommended as prophy- 
lactics, but the writer has rarely found any benefit from them, though 
they all will give some relief after the vomiting or nausea has set in. 
Nitro-glycerin is often very valuable, but- its use is unfortunately 
attended with such danger as prevents its being put into the hands of 
ordinary travellers. It sometimes does prevent sea-sickness, and the 
writer has observed a curious fact in connection with its action — viz., 
that if it fail to prevent vomiting, it often effectually removes the 
depression and apprehension accompanying the attack, some patients 
under its use feeling almost no nausea, though vomiting may be fre- 
quent, and a few apparently are almost able to enjoy the retching. Its 
danger lies in the possibility of the tablets (the only convenient form 
for administration) lying for a time undissolved in the stomaeh, and 
then getting into the circulation all at once. One of the tablets (y^ 
grain) may be given every hour for four hours. 

Nitrite of amyl may be used instead of nitro-glycerin, but its action 
is too fleeting. Antipyrine and antifebrin generally fail, their best 
effects are obtained when given frequently in small doses (2 grains), 
with cocaine (i grain). For the relief of the vomiting, when once 
established, any of the anodynes already mentioned as prophylactics 
may be tried. Ice sucked in the mouth, or iced champagne, or an effer- 
vescing alkaline mixture is indicated. Sinapisms or anodyne liniments 
may be applied to the epigastrium. Hydrocyanic acid, bismuth, crea- 
sote, and the usual gastric sedatives may have a trial, and lozenges of 
eucalyptus rostrata are said to be very efficacious. Food should be 
insisted upon after a time, owing to the danger of exhaustion setting in 
upon long voyages, and the appetite may be assisted after vomiting has 
ceased by the administration of a bitter combined with a mineral acid, 



SEBACEOUS CYSTS — SEPTICEMIA. 777 

as 15 minims of the diluted hydrochloric acid in a tablespoonful of 
infusion of gentian three or four times a day. 

SEBACEOUS CYSTS. 

The hair should be clipped close over the cyst when this occurs upon 
the scalp, and the skin cleansed by washing with a weak sublimate 
solution. An incision made with a fine scalpel suffices to permit of 
the shelling out of the cyst with its wall intact, the dissection being 
accomplished by a few strokes of the point or by the handle of the 
scalpel or blunt end of the forceps. Where these tumors are situated 
upon the face or forehead a very small incision into the skin and cyst- 
wall may be made, and by firm pressure of the thumb the sebaceous 
matter can be squeezed through the opening, after which the wall of 
the cyst should be forcibly dragged through the incision. It is more 
satisfactory to dissect out small cysts without rupture or extravasation 
of their contents, and no portion of their walls should be left behind. 
The lines of the incision should take the direction of any natural lines, 
furrows, or wrinkles, so as to avoid unnecessary marking. 

The after-treatment of the wound is to be conducted upon general 
surgical principles, but by far the best way is that which the writer 
always employs, viz. : After seeing that the hemorrhage has ceased and 
the wound rendered thoroughly aseptic by the free use of carbolic 
lotion, the lips are brought together and by gentle pressure for a few 
minutes every trace of moisture is dried up by absorbent wool, when a 
few layers of collodion applied over the wound and neighboring skin 
fixes the edges of the wound together, and by its pressure as it dries up 
it prevents further oozing, and almost always insures healing by first 
intention. 

[ ^The plan of causing suppuration by the application of caustics or 
the injection of irritants into the cyst has nothing to recommend itself. 
The injection of ether with the view of causing solution of the sebaceous 
matter and its subsequent absorption does not succeed. 

Where the cyst has already suppurated it should be treated as an 
ordinary abscess by a free incision, and its contents may then be washed 
out by any antiseptic solution. After the subsidence of all inflamma- 
tory action the cyst-wall may be excised if it has not already sloughed 
out. 

SEBORRHCEA— See Dandruff (page 166). 

SEPTICEMIA. 

In a general sense it may be said that the first thing to be done is 
to find out and treat the cause. As this is generally the result of some 
wound or injury through which the septic material has gained access 
into the system, it will be found necessary to open it up and establish 
free irrigation by antiseptic solutions. In the case of poisoned wounds 

50 



778 SPERMATORRHEA — SPINA BIFIDA. 

it will be necessary to destroy any poison at the seat of its admission 
by strong caustics, after which the freest outlet is to be established and 
ample drainage provided for, and all tension effectually removed. 
Poulticing, as ordinarily carried out, is to be avoided, antiseptics being 
preferable. Constitutional treatment, as detailed under Pyaemia, espe- 
cially pure air, abundant ventilation, milk diet, and strong soups at a 
later stage, with quinine, iron, salicylates, and the general remedies 
described under Pyaemia and Puerperal Fever, will be indicated. 

SHINGLES— See Herpes (page 362). 
SHOCK— See Collapse (page 133). 
SLEEPLESSNESS— See Insomnia (pages 401 to 413). 
SMALLPOX— See Variola. 
SPERMATORRHOEA. 

Under the heading of Masturbation the treatment of the common 
factor operating in the production of spermatorrhoea, in the great 
majority of cases, has been already detailed, and under Hypochon- 
driasis, page 380, the treatment of the mental state so frequently asso- 
ciated with it is described. If any local condition is discovered it should 
be remedied without delay, as elongated prepuce, fissure of the rectum, 
haemorrhoids, balanitis, phymosis, etc., the treatment for which affec- 
tions will be found in their proper places in the present volume. If 
the exciting cause of the discharge (which occurs without any sexual 
excitement) is remedied, the mental and physical condition may be 
expected to improve. 

Lallemand's treatment still finds acceptance with many surgeons. 
It consists in cauterizing the prostatic portion of the urethra by means 
of a solution of nitrate of silver (30 grains to 1 ounce) and a urethral 
syringe, or by applying the solid caustic with an instrument devised 
for the purpose. 

Phosphorus, arsenic, chloride of gold, electricity, massage, and the 
general treatment recommended under the head of Impotence, page 
391, may be resorted to in suitable cases, but more frequently the 
remedial and moral agents detailed under Hypochondriasis, on page 
380, will be indicated. 

SPINA BIFIDA. 

Of all the methods of treatment, the one now most frequently carried 
out is a modified form of Velpeau's operation. Until the infant's 
health and strength have been brought up to the standard requisite for 
an operation by judicious feeding and skilful nursing the operation 
should not be undertaken, the tumor being in the meantime protected 
by a layer of collodion, cotton wool, and a shield of gutta-percha 



SPINAL CURVATURE. 779 

modelled to suit the part. The tumor should be punctured through 
the healthy skin near to its base by a fine needle, and from one-third 
to one-half of its fluid contents removed, after which about one drachm 
of the following solution is to be injected. Large tumors may receive 
double this amount ; half a drachm will be sufficient for small ones : 

& . — Iodi purif. . gr. x. 

Potassii iodidi gr. xxx. 

Glycerini . . ^j. — M. 

It will be advisable to place the child upon its face during the oper- 
ation and to carefujly close the punctured opening by gentle pressure 
and collodion. One injection sometimes suffices, but it often may 
require several, the greatest care being taken to prevent injury to 
or rupture of the sac and loss or draining awav of the cerebro-spinal 
fluid. 

The operations of simply painting with collodion, tapping followed 
by compression, introducing setons, ligaturing the tumor, or excising 
a portion of the sac, being very seldom successful, and, except the first- 
mentioned, they are generally very dangerous. 

Recently Carl Bayer recommends the treatment of the tumor as if 
it were a hernia. He dissects out two lateral flaps from the skin cov- 
ering it and removes the sac, leaving only two lateral flaps of the 
dura, which he sews together after rendering the wounds aseptic, the 
skin and muscles being afterward brought together separately. He 
also suggests that two lateral periosteal flaps may be dissected from 
the canal of the sacrum in order to make a bony roof over the sewed 
sac. 

SPINAL CURVATURE. 

Under Caries, page 111, the treatment of antero-posterior curvature, 
or Pott's disease, is detailed. 

Lateral spinal curvature, if seen to before osseous permanent deform- 
ity has become established, yields rapidly to treatment. When con- 
firmed structural nerves exist, treatment is practically useless. 

In the early stages of the affection, all that is required is attention 
to the general health, suitable gymnastic exercise, and the avoidance 
of those habits and postures which have led to the development of 
the affection. The use of spinal supports, and rest for some hours 
during the day upon a couch, or confinement to bed, are positively in- 
j urious. 

Roth places the patient in a perfectly normal position (this is very 
easy in most cases where osseous permanent deformity has not set in), 
and he insists upon his maintaining this posture before a mirror, lying, 
standing, or sitting at regular intervals until his perverted muscular 
sense is restored. As soon as this occurs, the patient begins to realize 
that the easiest position has hitherto been the abnormal one. By 



780 SPRAINS. 

close attention afterward to the strict maintenance of the improved 
position in standing, sitting, or walking, a rapid cure results. In his 
able article in Heath's Dictionary of Surgery, a list of elaborate exer- 
cises are minutely given, to which the reader is referred. Games of 
all kinds, including rowing and lawn tennis, with the ordinary gym- 
nastic exercises, may be freely indulged in in all cases of lateral 
curvature, short of causiug severe fatigue or after-pain. The writer, 
contrary to the advice of some surgeons, always recommends swinging 
upon the horizontal bar, and finds that the improvement in the rapid 
development of the muscles of the back often effects a very speedy 
change. 

Where there is marked paralysis of the erectores spinse muscles, so 
that the patient is unable to assume an improved position, the use of 
a spinal support taking its fixed point from the pelvis, and lifting the 
weight of the head and upper extremities off the spine by means of 
two crutches made to fit into the armpits, affords considerable relief. 

As long as there is any hope of development of the weakened mus- 
cles in spinal curvature, however, these appliances do harm. 

They may occasionally serve in arresting the formation of perma- 
nent curves in rapid cases, but then only by being regularly used in 
conjunction with gymnastic exercises. 

Even in the most advanced cases of osseous deformity, their con- 
stant use often does harm, and the persistent employment of judicious 
gymnastic exercises may afford great relief to the wearying pains felt 
in the back and chest. 

Massage and electricity applied to the muscles of the back may do 
much when tried in conjunction with the above methods. 

SPRAINS. 

The treatment will vary with the time that has elapsed between the 
receipt of the sprain and the surgeon seeing the case. 

If seen immediately, or very soon after, before swelling has occurred, 
the writer has found the following simple plan act most satisfactorily 
in some cases : A rubber bandage is applied with moderate pressure 
to the joint, and the bandaged joint is placed under a cold water tap 
for as long as the patient can bear it. By this method sometimes the 
duration of the treatment may be limited from days or weeks to hours. 
If the pressure begins to give severe pain, the bandage must be taken 
off, and cold water applications continued. 

This combination of firm elastic pressure with continuous cold is 
the best measure when the sprain is seen early. Ice-bags, or an irri- 
gation apparatus, or ordinary cold evaporating lotions containing 
chloride of ammonium, lead or spirit, may be used instead, though, of 
course, these latter are only of use after the removal of the bandage. 

The plan of immediately enveloping the sprained joint in a firm 
plaster or starch bandage is highly recommended by many authorities, 
but the feeling that one cannot see what is going on under these when 



SQUINTING. 781 

pain afterward becomes severe, as it does in some cases, renders the 
mind of the patient or of his attendant uneasy, and the removal of 
such a bandage over a swollen limb is no easy matter. A properly- 
applied bandage should prevent swelling, but sometimes it does not, 
and then it is exceedingly painful. 

Warm applications are the most comfortable where severe pain and 
swelling have occurred before the surgeon has seen the case. Warm 
or hot fomentations or a good poultice is sometimes very soothing. 
Putting the limb into as hot water as the patient can bear may be 
tried. Upon the whole, however, the best all-round method is to 
envelop the joint with strips of lint soaked in the following lotion, or 
in spirit lotion (1:4), and then to carefully cover over with oiled silk 
or thin mackintosh, kept in its place by a light bandage : 

R.. — Liq. plumbi subacetat ^j. 

Tinct. opii ^ ij. 

Acid, acetic, dil ^ij. 

Aquae ad ^xx. — M. 

This may be applied warm. It also serves well if used as a cold 
evaporating lotion. 

Leeches applied to a very swollen and painful superficial joint often 
give more relief than anything else. 

Absolute rest is to be rigidly maintained until after the subsidence 
of the acute symptoms, and the starch or plaster bandages secure this 
most effectively when they can be tolerated. Any form of splint may 
be adjusted to the limb. As a rule, in ordinary practice, one generally 
finds that the rest is liable to be maintained for too long a period, and 
the method of keeping a plaster or starch bandage for six or eight 
weeks upon a sprained joint is to be condemned. Passive movements, 
friction, and massage may be commenced as soon as the disappearance 
of the pain and swelling. The too early use of the limb may lead to 
a slow convalescence, but the great majority of cases of stiffness and 
impaired use of joints after sprains are caused by an unnecessarily 
prolonged rest, which sets up changes in and around the joint. 

Mild sprains may be successfully treated by massage from the first. 
The patient should not be permitted to use the joint himself, or to 
place the weight of his body upon it until passive movement, massage, 
etc., can be tolerated without pain. In even the worst cases these 
agents may be commenced before the end of the third week. Strap- 
ping, consisting of soap or lead plaster spread upon any strong material, 
may be applied neatly round the joint in bad cases before the patient 
is allowed to move about. 

SQUINTING. 

The first consideration is to find out the cause and treat it, and if 
possible secure its removal. 



782 SQUINTING. 

Ordinary convergent strabismus is so very often the result of hyper- 
metropia, that atropine, in the majority of cases, will remove for the 
time the squint by paralyzing the ciliary muscles and putting an end 
to the attempts to accommodate. Sometimes eserine, by stimulating 
the muscular movement, will, by acting in the opposite way, remove 
the deformity for a short time. 

By correcting the hypermetropia, in some cases the strasbismus can 
be prevented, but in the majority of cases the use of convex glasses 
fails, owing to the changes which have already taken place in the rela- 
tions between the actions of the external and internal recti muscles. 
In all young subjects they should have a fair trial, especially where the 
squint is alternating and vision not permanently damaged. When this 
has threatened in young subjects the vision of the squinting eye should 
be treated by forced exercises. 

Where these measures fail, tenotomy of the internal rectus in one or 
both eyes must be resorted to. This should not be done sooner than 
the eighth year, by which time the patient will be able to wear glasses. 
It may be necessary to operate sooner if there are signs of the vision 
becoming affected, though by closing .the good eye several times daily 
and exercising the weak one this generally may be prevented and 
operation put off until the age specified. 

As it is often impossible to predict the exact amount of correction 
resulting from the operation, a second operation may be required, and 
where there is very marked strabismus it is better to operate upon both 
internal recti at the same time. 

After thoroughly rendering the conjunctiva insensible by cocaine, 
the tendon may be easily divided without giving any pain. The first 
step after the introduction of the speculum is to snip up a portion of 
the conjunctiva by forceps, and with the scissors produce an opening 
through which the hook and the blades of a pair of fine scissors may 
be passed, and as the tendon is caught by the hook it is divided by the 
scissors close to the sclerotic. 

Convergent strabismus, the result of myopia, is generally remedied 
by suitable glasses, but where these fail, tenotomy should be performed. 

Paralytic convergent strabismus must be treated by remedying the 
underlying mischief, which may be syphilitic, being often caused by 
the presence of gummatous tumors behind the orbit or by syphilitic 
affection of the orbital bones. While mercury or iodide of potassium 
is being employed, it will generally be found necessary to remedy the 
double vision caused by the strabismus by means of closing up one 
eye, and at several times during the day the affected eye should be 
exercised, so as to prevent wasting of the paralyzed muscles. For the 
same reasons massage and electricity may be used, and in very bad 
cases tenotomy will be required. 

Divergent squint is a more troublesome affection to remedy. The 
very mild forms may be sometimes removed by suitable concave 
glasses, to correct the myopia which is often the cause. 



STAMMERING— STARVATION. 783 

The external rectus will require tenotomy, while the internal rectus 
must be shortened or advanced. Success will to a large extent depend 
upon the state of the vision of the affected eye. 

Javal has recently reported a case where tenotomy had been per- 
formed on both eyes with unsatisfactory results, but success followed 
the use of the stereoscope after the patient had for a considerable time 
worked twelve or fourteen hours daily trying to produce single vision. 

It must be remembered that after tenotomy for strabismus the 
squinting eye must be constantly and steadily exercised, otherwise the 
sharpness of vision will not be improved. 

STAMMERING. 

After remedying any local abnormalities or diseased conditions of 
the mouth, throat, or air-passages, the treatment must be purely edu- 
cational. The greatest slowness and deliberation must be maintained 
during the necessary vocal exercises. Nothing, however, will be gained 
without the exercise of much patience. 

The patient should read aloud slowly with a good teacher, practising 
over and over again the combinations of sounds which give the greatest 
difficulty, with patience and deliberation. In very bad cases a begin- 
ning may be made by singing or intoning, after which, by repeated 
exercises in loud, slow reading, improvement will gradually show 
itself. 

Rules are useless for such exercises. The assistance of an experi- 
enced teacher is of all things the most important, and the patient 
should be educated as far as possible to refrain from speaking when 
under the influence of nervousness, excitement, or passion. 

Corval has reported astonishing results from hypnotism, the effects 
being speedy, and in some cases complete cure results. 

Various drugs, as bromides, hyoscyamus, stramonium, etc., and most 
antispasmodics have been tried, but they are useless as a rule. 

STARVATION. 

The obvious remedy for this condition is food, but the most cautious 
and discreet exhibition of aliment is essential. Death rapidly super- 
venes in many cases where the sufferer is permitted to suddenly satisfy 
the cravings of hunger following a forced abstinence from food. The 
most easily digestible substances should be sparingly administered at 
very short intervals, and milk, beef tea, or meat juices afford the safest 
means of supplying these. Solids must be sparingly administered for 
some time, or entirely withheld until the digestive organs recover suffi- 
cient tone. White fish, boiled, is the best form in which to commence 
the exhibition of solids. Children and infants, upon being rescued 
from a state of acute or chronic starvatien, do best upon diluted warm 
peptonized milk. 

A matter of vital importance, which may be readily overlooked in 



784 STERILITY. 

these cases, is the state of the body temperature. In starvation this 
falls so low as to cause death, and life may be saved in some cases by 
a prompt application of dry heat to the body of the victim rescued 
from starvation. In some cases heat is more urgently demanded than 
food. It is advisable to apply hot water bottles and warm flannels or 
cotton wool rather than at first to attempt friction or massage, which 
might possibly, under such circumstances, extinguish life. 

In the voluntary starvation of lunatics, the gag and the rubber tube 
of a stomach pump may be employed to convey liquid food into the 
stomach, or, where there is difficulty in introducing the tube through 
the mouth, it may be sometimes passed along the floor of the nares. 

STERILITY. 

Though there should be a clear line drawn between impotence and 
sterility, the reader is referred, in connection with this subject, to the 
article under Impotence upon page 391. 

The treatment of sterility in the male will resolve itself into the 
remedying of the causes, as far as these are capable of remedy. Where 
impotence is absent, and the sexual act is performed in the normal 
manner, but where there is absence of spermatozoa from the seminal 
fluid, little need be expected from any method of treatment unless in 
those rare cases where the azoospermatism is caused by some tempor- 
ary obstruction of the efferent ducts of the testicles, as from recent 
epididymitis, when appropriate remedies may be of use. Should this 
condition depend upon exhaustion from recent venereal excesses, with- 
out impotence, abstinence will generally correct it in a short time ; but 
where prolonged abuse of the sexual instinct has led to marked atrophy 
of the testicles, no medication will be of the least use in cases where 
spermatozoa are absent from the seminal discharge, or in cases where 
both testicles are retained in the canal or abdomen. 

In sterility caused by absence of the seminal emission at the time of 
sexual intercourse, if this depends upon any mechanical impediment, 
as phymosis, hypospadias, diseases or concretions in the prostate, stric- 
ture of the urethra, etc., it may be remedied effectually by removal of 
these causes. 

Where, from nervous or physical causes, the discharge of seminal 
fluid is delayed or absent, though the sexual act may be otherwise suc- 
cessfully performed, treatment generally is of little avail, though in 
such comparatively rare cases the remedies mentioned under impotence, 
as phosphorus, strychnine, electricity, etc., may have a trial. Curling 
and McCarthy recommend the application of blisters and irritants to 
the glans and penis in those cases characterized by deficient sensibility 
of this portion of the genital apparatus. 

Sterility in the female often depends upon remedial causes, and it 
must be borne in mind that not unusually more than one cause may 
be present at the same time, and the mistake should not be made of 



STINGS — STOMATITIS. 785 

stopping short of correcting abnormal conditions of the various parts 
of the general tract. Details of treatment here are unnecessary, as 
they are supplied under the different headings of the abnormal or 
diseased condition interfering with conception, as Uterine Displace- 
ments, Metritis, Leucorrhoea, Ovarian Disease, Gonorrhoea, Vaginis- 
mus, Dysmenorrhcea, Tumors, Salpingitis, Syphilis, Obesity, etc. 

STINGS. 

In the case of wasp and bee stings the immediate application of 
liquor ammoniac gives almost instantaneous relief. Sal volatile 
answers the same purpose, but acts less rapidly. Where the sting is 
left in, it should be extracted by forceps, and in the coarse skin of the 
palms of the hands or soles of the feet the strong liquor may be 
applied. Alkaline carbonates may be employed in the absence of 
ammonia. Thus a strong solution of carbonate or bicarbonate of 
sodium or potassium may be tried. Chloroform or strong oil of pepper- 
mint gives relief, and a little pure carbolic acid may be applied on the 
end of a match to the puncture," or carbolic oil (1 : 8) may be more 
freely applied. 

If erythema and swelling have already appeared, ammonia may 
increase the irritation. In such cases a poultice with some alkaline 
solution, as lime-water, sprinkled over its surface acts well. 

Peppermint oil relieves the pain and irritation of mosquito bites, and 
pennyroyal oil (hedeoma pulegioides) is much used both as a remedy 
and preventive. Camphor, oil of cloves, oil of cinnamon, and oils of 
rosemary, eucalyptus, or cajuput act in the same way as preventives. 
Poultices of ipecacuanha and mint leaves relieve mosquito bites. 
Scorpion stings are also successfully treated by ammonia and chloro- 
form, alum, and carbolic acid. 

Where sudden collapse follows the stings of bees, wasps, or scor- 
pions, ammonia and brandy or whiskey internally may be urgently 
required. Spider bites are best treated by carbolic acid, and some- 
times a small incision to permit the entrance of the acid into the 
immediate region of infection. A ligature around the limb if applied 
at once in the absence of remedies, will give time for the destruction 
of the poison by sucking, washing, or cauterizing the spot in cases 
where a severe or dangerous result might be anticipated. 

STOMACH, Diseases of— See under Dyspepsia, Gastralgia, Gas- 
tritis, Gastric Ulcer, Cancer, etc. 

STOMATITIS. 

Under cancrum oris (page 109), the treatment of the gangrenous 
variety of stomatitis is described. For the catarrhal, ulcerative, and 
follicular varieties the treatment is simple, and may be carried out 
upon much the same lines as that of aphthous stomatitis (page 51). 



786 



STOMATITIS. 



Diet should be as nutritious as possible, and for children peptonized 
milk foods or peptonized beef-tea and chicken soups are required. In 
all cases of severity a liquid food is necessary, and upon investigation, 
something will generally be found to have been wrong with the feed- 
ing and general management of the patient prior to the attack. 
This should be corrected at once. Food should be properly cooked 
and given at proper intervals. Pure fresh air and sunlight are neces- 
sary and everything that can place the patient in the most favorable 
hygienic condition should be resorted to. Local treatment is of im- 
portance, and all cases generally soon yield to the continuous use of 
the glycerin of borax (1:4). This preparation should contain no 
water, as it should be of such consistence as to adhere to the mucous 
surfaces. It should be applied by means of a brush or by the finger 
every two or three hours. 

In the cases of minor severity coming on during the course of other 
diseases in adults, the writer's plan is to give one large crystal of borax 
to the patient, with directions that he is to lick it frequently through 
the day. 

Chlorate of potassium, in the form of tablets, is an excellent remedy. 
One may be kept in the mouth and allowed to dissolve very slowly. 
Like borax, if its use be continued after the disappearance of the 
stomatitis, it may set up an irritation of its own, which, however, 
ceases as soon as its use is suspended. It is frequently used in solution 
(J ounce to 1 pint). Boric acid (1 : 30), carbolic acid (1 : 100), glyce- 
rin of alum (1 to 5), salicylate of sodium (1 : 20), or lime-water may be 
used. 

The occasional use of a weak solution of corrosive sublimate, 1 
grain in 6 ounces distilled water, is advisable in the stomatitis of 
adults. 

Where ulceration is extensive the sores may be touched with solid 
nitrate of silver, or brushed over with a strong solution. The sulphate 
of copper, burned alum, and strong hydrochloric acid are used for 
this purpose. A weak solution of permanganate of potassium may be 
frequently used where there is much fetor. 

Where bleeding from the ulcerated spots occurs vegetable astring- 
ents as decoction of oak bark, rhatany, myrrh, etc., may be useful. 

Where the state of the mouth is such as to render feeding very 
painful, cocaine may be employed, or even forced feeding with a 
rubber tube, or rectal alimeutation may be resorted to. 

Of internal remedies none equals a combination of iron and chlo- 
rate of potassium, which may be safely given at all ages : 



R . — Potassii chlor. . 
Tinct. ferri chlor. 
Glycerini 
Aquse dest. 
S. — One tablespoonful four times 



ad 



gss. 
^ss. 

ij- 

gxij.-M. 



a day in a little water. 



STONE IN" THE KIDNEY. 787 

Infants may take a small teaspoonful of the above. 

Tincture of cinchona may be added where there is much depression, 
and cod- liver oil is always useful. 

Mercurial stomatitis is best treated by constant washing out of the 
mouth by means of chlorate of potassium washes (1 : 30) ; in the intervals 
the tablets of the same substance may be employed, and where there is 
much fetor chlorine solution or permanganate may be freely used. At 
a later stage the vegetable astringents are indicated. 

Internally chlorate of potassium is the best remedy, and it is hardly 
necessary to state that mercurials are to be suspended. 

For the not uncommon condition known as " spongy gums " gen- 
erally depending upon an abnormal condition of the secretions of the 
mouth, or upon the presence of tartar, attention to the general health, 
especially to the gastric or digestive functions, and the removal of 
tartar, are essential. Chlorate of potassium may be used in the form of 
tablets, and the following local application is of the greatest value : 

R . — Tinct. myrrhse 
Tinct. kranieriae 
Tinct. cinchona? 
Tinct. catechu comp. 

Eau de Cologne Jj j. — M. 

S. — A large teaspoonful in a wineglassful of water to be used as a mouth-wash 
frequently. 

STONE IN THE! KIDNEY. 

The treatment of this generally very painful affection will depend 
upon the stage of the disease or upon the symptoms present when the 
case first comes under notice. 

Renal colic, or the pain produced by the calculus finding its way 
into the pelvis of the kidney or into the ureter, is best relieved by a 
hot bath given as soon as possible after the commencement of the 
attack. The patient should remain in the bath under the charge of a 
discreet attendant until the full antispasmodic effect of it is observable, 
i. e., until he complains of weakness or a feeling of syncope. This is 
undoubtedly the best routine treatment to adopt whenever it is avail- 
able. Under its influence the spasm of the ureter may relax, and 
small calculi may find their way speedily into the bladder. Opium in 
small doses (15 minims of the tincture) may be given every half hour 
for three or four hours if the agony is severe, and this drug may be 
commenced while the bath is being prepared, and it may be continued 
during immersion. 

Morphine hypodermically gives the speediest and most effectual 
relief, and it may be resorted to immediately when the pain cannot be 
tolerated. One-third or one-half grain may be injected under the skin in 
the neighborhood of the affected kidney, but, upon the whole, it is wiser 



788 STONE IN THE KIDNEY. 

to wait until after the hot bath has been taken, when, if relief be not 
obtained, it may be injected as the patient is put to bed with warm 
water bottles applied to his loins. 

The physiological effects of the drug should be produced, and as these 
require very large doses in many cases, the writer's routine practice is 
to give first a full dose of whiskey (1 to 2 ounces), and then the hypo- 
dermic of morphine, combined with two minims of the (1 : 100) solu- 
tion of atropine. With these precautions, full doses of the drug may 
be given safely. Moreover, the action of the atropine assists that of 
the morphine, while it prevents any depressing effect upon the heart. 
In patients subject to attacks of renal colic it is a good plan to advise 
a large warm water enema, followed by a morphine suppository 
(J grain), to be used as soon as the attack threatens, while the bath is 
being prepared. The temperature of the bath should commence at 
100° F. and be raised to 104° or 106°. A hot pack may be resorted 
to in the absence of the bath. 

Hot stupes to the loins, hot poultices, and cupping may be resorted 
to with advantage. Manipulation of the ureters through the abdominal 
walls and inversion of the body have sometimes given good results. 

Local anodynes have little effect ; and the new analgesics, as anti 
pyrine, exalgine, etc., generally fail entirely. 

During the intervals of the attacks an attempt may be made to 
carry out Roberts' plan of dissolving the calculus. This need only be 
thought of where there is reason to believe that it consists of uric acid, 
urates, or cystine, all of which are soluble in alkalies. If the stone 
should consist of oxalate of lime the alkaline treatment will do no 
harm, and in all cases where the urine is acid the alkaline solvent 
method should have a full and fair trial, especially as it can do no 
harm, and in the majority of cases no other plan is available. The 
writer believes that he has obtained good results by the use of alkalies 
in full doses. 

Roberts insists that, to be of any use, the urine must be kept con- 
tinuously alkaline for long periods. The dose must be given every 
three hours at least during the waking hours, and during the night 
when the patient is awake. The citrate and the acetate of potassium, in 
doses of 40 to 60 grains dissolved in 3 or 4 ounces of water, are the 
best alkalies, and he advises that the citrate from the shops is not to 
be relied upon, but that it should be prepared fresh by neutralizing 
the crystallized bicarbonate with crystallized citric acid, as in the 
following formula : 

B. — Potassii bicarb. . ..... ^xx. 

Acidi citric 3 xiv. 

Aquse dest ad ^ rx. — M. 

This yields one drachm of the citrate of potassium in each fluidounce, 
the dose for adults being 6 to 8 drachms in a claretglassful of water, 
and for children half this amount. 



STONE IN THE KIDNEY. 789 

Hematuria and other symptoms, when they show themselves, must 
be treated by absolute rest and the appropriate remedies mentioned 
under their separate headings. (See Hematuria, Pyonephrosis, Hydro- 
nephrosis, Pyelitis, etc.) 

If the symptoms warrant a positive diagnosis, and by their severity 
render the patient's life unbearable, an attempt should be made to 
'remove the stone. Where there is no evidence of any suppuration or 
disorganization of the renal organ present, the operation of nephro- 
lithotomy has given brilliant results in some cases. Its mortality when 
performed early is exceedingly low in all cases where there is no dis- 
organization of the gland. It is practically the same operation as 
nephrotomy, only, .owing to the absence of the great enlargements 
usually met with in cases where the kidney is enlarged or extensively 
diseased, the operation is often more difficult. It is rather unfortunate 
to call the operation by different names — viz., nephro-lithotomy when 
it is performed upon a healthy kidney, and nephrotomy when the 
same operation is performed upon a kidney the seat of pyelitis, pyo- 
nephrosis, etc. 

The operation itself consists of making a free incision into the 
kidney. The organ is reached by making an incision in the lumbar 
region between the last rib and the iliac crest at the external border 
of the erector spinse. When the kidney is reached and carefully ex- 
plored, a free incision is made into its substance or into its pelvis and 
the calculus removed ; the wound afterward being thoroughly drained 
by a tube passed down into the incision in the renal substance or its 
pelvis, the strictest antiseptic precautions being maintained before and 
after the operation. 

Where extensive disorganization of the kidney is found to be pres- 
ent, the operation of nephrectomy or removal of the whole kidney may 
have to be carried out. If this is contemplated from the first, it may 
be performed by abdominal section in the middle line, or by an incision 
through the linea semilunaris ; or if a nephrotomy or a nephro-lithotomy 
is attempted at first, the entire organ can be removed through the 
lumbar incision by modifying the procedure when the examination 
shows that the kidney itself must be removed. 

In those rare cases where a calculus blocks up one ureter, the oppo- 
site organ having been rendered useless by a similar event some time 
previously, there is little hope for the patient unless the recently-formed 
stone descends into the bladder. In such an instance abdominal sec- 
tion may be imperative in order to give the patient the only chance 
for his life. There have been recent successes following this bold pro- 
cedure. The writer had such a case lately, but unfortunately the 
calculus descended into the pervious ureter just at the time of parturi- 
tion, and an abdominal section under such circumstances was regarded 
as hopeless. 



790 STONE IN THE BLADDER. 

STONE IN THE BLADDER. 

In the case of the female the treatment of this affection is a simple 
matter in the majority of instances. Dilatation of the urethra by the 
blades of a stout pair of dressing forceps, or by an instrument devised 
for the purpose, should be performed, and if extraction of the stone is 
not easily affected after being seized by suitable forceps, it can be 
crushed by a lithotrite and removed at once. The writer years ago 
had several cases of stone in children, and no incontinence followed 
the dilatation of the urethra to the extent of admitting the little 
finger and exploring the bladder. Soft stones can be safely broken 
up by a pair of necrosis forceps, and the fragments extracted, taking 
care not to cause laceration of the passage or injury to the neck of the 
bladder. Large stones must be crushed with the lithotrite, but if of 
very great size and hard they may be removed by the vagina or by 
the supra-pubic method. 

In males the operation is, of course, very different. Should solvent 
treatment have a chance ? Nearly every surgeon answers this strongly 
in the negative, nevertheless there is unquestionably sufficient evidence 
to show that in a narrow minority of cases it should have a trial. As 
pointed out by Roberts it is absolutely useless in all cases where ■ the 
urine is ammoniacal, and in all cases of oxalate of lime and phosphatic 
calculi, and it is only applicable in those cases of vesical calculi in 
which the urine is acid ; the stone not large ; its composition known to 
be, or strongly suspected to be, uric acid. 

In a patient who has recently had an attack of renal colic, followed 
by evidence that the stone has descended into the bladder, where the 
urine is acid, and where a former uric acid stone or uric acid gravel 
had been passed, the writer is satisfied that the only course open (in 
the absence of severe bladder disturbance) is to give the continuous 
alkaline administration a fair trial, but it must be rigidly carried out 
as described upon page 788. He has satisfied himself often that strict 
adherence to this method will facilitate the passage of uric acid stones 
through the urethra, which might not otherwise have been voided, but, 
of course, such an opinion is not worth much if one only lets one's 
mind dwell upon the fact that the great majority of stones passed down 
the ureters into the bladder are expelled in the urine. 

If upon sounding, a stone is struck, the generally accepted rule is 
immediately to consider whether the case is one for lithotrity or lithot- 
omy, it is difficult to decide the size of the calculus, but in the great 
majority of cases coming under the care of the surgeon that is already 
so large as to be considered out of the reach of solvents. The writer 
once got a clear tinkle from a stone not much larger than a red cur- 
rant. Perhaps one of the reasons why the solvent method meets with 
so little sympathy from the surgeon may be owing to the fact that the 
specialist does not, as a rule, get the cases in as early a stage as they 
are met by the physician. 

There are sufficient cases on record to show that phosphatic calculi 



STONE IN THE BLADDER. 791 

may be dissolved by injections of diluted nitric acid into the bladder 
(1 of the dilute acid to 80), but the process is surrounded with such 
difficulties in carrying it out that it has been little practised. It may, 
however, be resorted to in the intervals of crushing such stones where 
phosphatic deposits are taking place as they do sometimes with rapidity 
upon the fragments before their emission. Alkaline injections into the 
bladder for uric acid calculi are not to be undertaken when the stomach 
answers the same purpose so readily. The solvent action to be of use, 
as already pointed out, must be practically continuous and must be 
carried out for many weeks. This can be done without any danger 
to health, as is seen at Vichy and other alkaline springs. 

Notwithstanding all that can be said for the solvent treatment, it is 
a very trivial minority of cases coming under the care of the surgeon 
in which it can be successful, and the practical question in the treat- 
ment of stone is to decide the question of crushing or cutting. 

In children the cutting operation has generally been preferred ; but 
since the introduction of litholapaxy by Bigelow, in which the stone is 
crushed and its fragments removed at one sitting, some boys who for- 
merly would have been submitted to the cutting operation are now 
successfully operated upon by the crushing method, and Marshal and 
many others believe that the cutting operation, even in the case of 
boys, should be now seldom resorted to. It must, however, be remem- 
bered that the cutting plan in children is followed by such a very low 
mortality that it will be long before it will go out of fashion. 

In adults, with calculi under one and a half to two inches, lithotrity 
should have the preference. Large stones should be removed by the 
suprapubic method. Very hard uric acid or oxalate of lime calculi 
may resist the lithotrite, and then lithotomy must be resorted to ; but, 
upon the whole, there cannot be any doubt but lithotrity is all round 
a safer operation, and the number of cases in which it is inadmissible 
is small. Stricture of the urethra and enlargement of the prostate are 
no barriers to crushing. The urethra may be gradually dilated by 
solid metal bougies up to No. 16 just before the operation, and with 
prostatic enlargement the washing out apparatus overcomes all diffi- 
culty. 

Deformity of the urethra, as may be seen in rare conditions where 
some old injury or abscess has led to its cicatrization, may demand 
lithotomy. The scale between the two operations may also be turned 
by a very unhealthy and irritable state of the bladder. Where there 
is evidence that the kidneys are diseased and an operation is impera- 
tive, crushing is safer with any reasonable sized calculus. If a foreign 
body (catheter, etc.), is known to form the nucleus of a calculus, cut- 
ting must be determined upon. 

Lithotrity is now carried out, generally at one sitting, by removing 
all the crushed fragments and debris by means of a suction apparatus. 
It is considered necessary to give an anaesthetic or inject 1 or 2 drachms 
of a 4 per cent, cocaine solution. Much will depend upon the patient, 



792 STONE IN THE BLADDER. 

upon the state of his bladder, and upon the size of the stone. Once 
the writer had to crush a small stone in a patient who could not bear 
an anaesthetic (before the days of cocaine), and he was surprised to see 
how little pain need be inflicted during the operation. In cases where 
the crushing, except of very small stones, is to be carried out at one 
sitting, the use of the anaesthetic is necessary. The patient being placed 
upon his back, with the pelvis slightly elevated, and the operator stand- 
ing upon his right, the lithotrite, well lubricated, should be passed 
gently into the bladder. Before operating it must be seen that the 
bladder contains at least a couple of hours' urine ; if not, 4 or 5 ounces 
of warm boric acid solution may be gradually injected.- 

As the lithotrite glides into the bladder the handle is raised, and the 
female blade pushed gently down, so as to slightly depress the floor of 
the cavity. When this manoeuvre is skilfully executed the stone often 
drops into the blade, and is seized in position by the male portion of 
the instrument and crushed. Where this plain fails, the lithotrite, 
with its open blades, is turned from side to side or inverted so as to 
pick up the calculus from the floor of the bladder. This latter method 
suits best in all cases where the prostate is enlarged. 

After screwing home the blades they are again separated, and any 
large fragments picked up in turn and crushed. The same lithotrite 
will do in most cases of small stone, but for large ones some operators 
prefer to crush first with a strong instrument, and then use a small one 
for the fragments. 

The lithotrite should not be withdrawn until it is screwed tightly 
home. The evacuating catheter is then introduced, and the aspirator 
attached. A stream of water is sent into the bladder by a sharp squeeze 
of the rubber bottle, and, as the pressure is withdrawn, the water is 
sucked back, bearing detritus and small fragments with it, which fall 
into the glass reservoir. If the fragments are not all removable a 
second or third crushing of them may be necessary, using the aspirator 
after each operation, until every particle of the stone is removed when 
possible. With a very neat and careful operator no blood may be 
seen in some cases, and little irritation may result with small stones. 

The after-treatment consists in a morphine suppository, diluent drinks, 
rest in bed, warm baths, a few drops of boric acid, and a restricted diet. 
If cystitis follow, it must be met by the remedies detailed under its own 
heading. 

Lithotomy aims at removing the stone by an incision into the bladder 
where it is uncovered by peritoneum, either through the perineum or 
above the pubes. Only the merest outline of these operations need be 
given, with the view of refreshing the student's memory. 

The lateral operation is performed by incising the membranous and 
prostatic urethra and the left lobe of the prostate. 

After the rectum has been emptied, and the patient placed upon a 
suitable table in the lithotomy position, by the assistance of bandages 
or anklets or Clover's crotch, and under the influence of an anaesthetic, 



STONE IN THE BLADDER. 793 

the staff is passed into the bladder and made to strike the stone. The 
bladder should be moderately full. The staff is then entrusted to a 
reliable assistant, who holds it firmly up hooked under the pubic arch. 
The operator introduces his finger into the rectum, and takes the bear- 
ings of the various regions, feeling for the apex of the prostate and the 
staff, and, feeling all satisfactory, he withdraws the finger again. 

An incision about three inches long is made in the shaven perineum, 
commencing about one inch and a half above the anus, just to the left 
of the middle line, and carried outward and downward toward the 
ischial tuberosity, about one inch and a quarter outside the anus, 
through skin and superficial fascia, but without striking the staff, which 
is to be felt for by pressing the left index-finger into the upper end of 
the wound. As soon as the groove is felt, the point of the knife is 
inserted into it, and the membranous portion of the urethra divided as 
the knife is pushed along the groove until the bladder is reached, cutting 
the left lobe of the prostate and neck of the bladder. If the stone is a 
large one, the incision may be increased as the knife is withdrawn by 
allowing it to leave the groove, or by thoroughly lateralizing it, with 
its back kept firmly in the groove. If the straight staff has been used, 
the operator at this stage takes the staff in his left hand after inserting 
the point of the knife into its groove, and rotates it until the proper 
angle is obtained, when the prostate is divided as the knife enters the 
bladder. 

After the withdrawal of the knife, the left index-finger is introduced 
along the staff into the bladder, and when the stone is touched the staff 
may be removed. A pair of lithotomy forceps are now guided along 
the finger, the stone seized, and extracted. The gush of urine follow- 
ing the withdrawal of the left index-finger generally carries the stone 
between the open blades of the forceps. 

The patient should be put to bed with a pillow under his knees, and 
a good draw sheet. An anodyne may be given, and a light diet 
administered. 

The median operation, which is becoming less employed, is only suit- 
able for small stones. After the patient has been placed in the usual 
lithotomy position, a curved or rectangular staff,- with a median groove, 
is passed into the bladder, and held by an assistant as in the lateral 
operation. The operator then passes his left index-finger into the rec- 
tum, with its palmar surface upward, aud the tip resting against the 
apex of the prostate. A long, straight bistoury is entered half an inch 
in front of the bowel, passed through the raphe with its back to the 
bowel, until the staff is reached at the apex of the prostate, and after 
being pressed for a short distance toward the bladder, it is made to 
cut upward, dividing the membranous portions of the urethra to the 
required extent. The finger is then introduced into the bladder upon 
a blunt probe, and the stone caught and extracted as in lateral 
lithotomy. 

The supra-pubic operation is now performed for large calculi in the 

51 



794 STONE IN THE URETHRA. 

following manner : The urine is drawn off by the catheter, and the 
bladder is filled with warm boric lotion, and this is kept in by a liga- 
ture around the penis. The rectum is filled by a thin rubber bag, into 
which 10 to 15 ounces of warm water are injected. By these means the 
fold of peritoneum is lifted high up out of danger from the knife, and the 
bladder pushed up in the pelvis. An incision about three inches long 
is made in the middle line above the pubes through the linea alba, and 
by the finger-nail, a blunt director, or the handle of the scalpel, the fat 
is dissected aside until the bladder is reached. This is fixed by a 
tenaculum, and opened hehind the pubes, so as to make an entrance 
for the finger, which, after measuring the stone is withdrawn, and the 
opening enlarged to the required extent, or the opening may be en- 
larged, the finger acting as a director, after which the stone is extracted 
by suitable forceps. As regards the after steps, there is much diversity 
of opinion, some operators simply leaving the bladder and skin wounds 
open, others insert a long rubber tube into the bladder, others suture 
the bladder wound, and some insist upon a catheter being tied in the 
urethra. Attention should be paid to the position of the patient, so as 
to insure the most thorough drainage.- 

STONE IN THE URETHRA. 

With a calculus impacted in any portion of the. passage, it is well 
not to think of pushing it back into the bladder until other measures 
fail. By skilful manipulation a small stone may be pressed forward 
by a gentle kneading movement, executed by grasping the penis be- 
tween the fingers if in the penile portion of the urethra. 

By stopping the flow of urine for a little, and suddenly causing a 
quick contraction of the bladder and accessory muscles, it may be 
squirted out if the obstruction is not complete. 

A pair of urethral forceps may be passed down to the impediment, 
and, aided by external manipulation, the operator will often succeed 
in seizing it. 

A scoop or loop, such as is used for the removal of foreign bodies 
from the ear, may be passed beyond it, care being taken by external 
pressure to prevent its return to the bladder. 

If failure attend these methods, an incision may be made and the 
stone pushed out from behind by a probe or catheter introduced into 
the wound. When far back, the median lithotomy operation may be 
tried. In adults it is better, when extraction fails, to push the stone 
back into the bladder by a blunt bougie, or by a catheter with the 
opening at the very point. When forced back, it can be easily crushed 
by a fine lithotrite in the bladder. 

As the stone is brought forward, if extraction by scoop, forceps, or 
external manipulation succeeds, it may be found to stick fast in the 
fossa navicularis, from which it may be only possible to release it by 
incising the meatus. 



STRANGURY — STRICTURE OF THE URETHrRA. 795 

In neglected cases, where extravasation of urine has already occurred, 
free incisions into the perineum and surrounding tissues must be made 
without delay, after which the calculus may be removed by cutting 
down upon a staff passed as far as the obstruction. 

STRANGURY. 

The cause must be first found out and removed, when this is pos- 
sible. Stone in the bladder, ureter, or urethra, or inflammation of 
these parts may exist, and their proper treatment will be found detailed 
under their separate headings. (See Stone, Cystitis, Bright's Dis- 
ease, etc.) 

Where the symptoms are caused by the external or internal use of 
cantharides, or by the administration of copaiba, sandal wood, or tur- 
pentine, the use of the drug should be instantly suspended. 

A good hot bath or hot sitz bath, with warm diluent drinks, or 
iced water, a morphine suppository in the rectum, followed by con- 
tinuous hot fomentations applied to the perineum, and, in very painful 
cases, a hypodermic injection of morphine and leeching may be tried. 
Blisters should be used with great caution on patients the subjects 
of Bright's disease or bladder affections, and in young or debilitated 
persons. When necessary in these cases, they should not be kept on for 
more than two or three hours, and after their removal a poultice should 
be applied. 

STRICTURE OP THE GULLET. 

Under Cancer of the Gullet (page 101) the treatment of malignant 
stricture is described. Under CEsophagus, Stricture of, upon page 551, 
the treatment of simple stricture is detailed. 

STRICTURE OP THE INTESTINES— See under Intestinal Ob- 
struction, page 415. 

STRICTURE OP THE RECTUM — See under Cancer of the 
Rectum, page 105. 



STRICTURE OP THE URETHRA. 

The applicability of the various methods of treating the varieties of 
this condition will be referred to later on. The method of intermittent 
or interrupted dilatation is applicable to the great majority of organic 
strictures through which an instrument can be passed. 

Though most successful in strictures of recent formation owing to 
its painlessness, simplicity, safety, and convenience, often the surgeon 
gives it a trial when the aspect of the case, its great duration, and the 
density of the tissues entering into it, and other characteristics indi- 



796 STRICTURE OF THE URETHRA. 

eating some of the more severe operations, might tempt him to begin 
with a section of the urethra. It is, moreover, the practice selected in 
those cases where, owing to serious disease of the kidneys, a radical 
cure of the contracted region is neither possible nor its attempt com- 
mendable. 

Various instruments are used, and it need hardly be insisted upon 
that, in the absence of retention of urine, catheters should not be 
employed. Differences of opinion exist as to the preference to be 
given to soft or solid metal bougies, some surgeons insisting upon the 
routine employment of one kind to the exclusion of the other. It 
will be safe to adopt, under ordinary circumstances, the following 
practice, especially if the operator have not much experience — i.e., to 
employ soft gum-elastic bougies when the opening is as small say as 
a No. 5 English, or less, and to always use metal ones for wider 
strictures. 

There is considerable danger in passing small metal instruments, 
except by the most experienced. Heavy, solid bougies for all sizes of 
stricture are better in skilled hands than gum-elastic instruments for 
interrupted dilatation, though it will be safer to begin with the latter in 
narrow strictures. 

The old-fashioned, highly-polished bellied sounds of Sir Henry 
Thompson are the best. They .have a wide curve, and are so tapered 
that the widest part of the instrument fills the stricture after it has 
been dilated by the thinner portion as it is gently pressed on toward 
the bladder. Tortuous strictures cannot be safely treated with rigid 
instruments until after partial dilatation by pliable ones. 

Having placed the patient in the best possible condition of health, 
and having his bowels cleared out (and a warm bath given in some 
cases), he is sent to bed for a few hours earlier than usual, and the 
treatment may be inaugurated. This latter precaution is a wise one 
if the operator has not had any previous experience of the patient's 
power of tolerating urethral interference. It will be well to begin 
the treatment after he has got warmed in bed, and where he can 
remain until next morning. In this way rigors, etc., may be pre- 
vented until the patient gets accustomed to the use of instruments. 
At subsequent dilatations this will be unnecessary. It will, however, 
be always necessary to caution the patient against walking or other 
exercise, and against exposure to chills for some hours after the pas- 
sage of instruments. 

Beginning with an instrument that will just slip through the stricture 
upon the lightest pressure, the next size is to be gently passed, and 
sometimes the succeeding size may be manipulated through at the first 
sitting. Force, in the ordinary sense of the word, is never to be used, 
and it is better to be content with making gradual headway. The 
bougies or sounds should be warm and well lubricated with lard, 
vaseline, carbolized oil, or Lund's lubricating oil. The writer prefers 
a thick glycerin of borax (1 ; 5) for this purpose, and has never been 



STRICTURE OF THE URETHRA. 797 

disappointed with it ; it never becomes rancid, and it is always aseptic, 
and never irritates the urethra. 

The length of the intervals between the sittings is to be regulated 
by the amount of dilatation accomplished, and by the tolerance of the 
urethra. Every third day until headway is made, then every seventh 
day is a safe rule. In the case of a stricture which contracts rapidly, 
it may be safely attacked twice a week. 

At the commencement of each sitting it is well to begin with a size 
smaller than the one last employed at the former sitting. Any irrita- 
tion of the bladder or urethra should be subdued before commencing 
or resuming operations. 

As the stricture becomes widened, and the larger sizes can be passed, 
it is an excellent plan to leave the instrument in for ten to twenty 
minutes before finishing up the sitting ; but this practice only excites 
pain and irritation until the stricture is accustomed by weeks of inter- 
rupted dilatation to tolerate the presence of the bougie. 

The sittings should be continued until a No. 15 English instrument 
can be easily passed. To stop at a No. 12 is a mistake, as inevitable 
shrinkage follows. It is the non-observance of this rule which leads 
to failure in the hands of most men. Though the stricture cannot be 
regarded as cured in the great majority of cases, nevertheless, by 
dilating the urethra up to its fullest capacity, the very best results 
are obtainable, and in some cases no narrowing may be detected for 
years. 

It is essential, however, that the patient be taught to pass at least a 
No. 12 English gum elastic bougie every month for three or four 
months, then every three or six months, returning once a year to have 
the largest (No. 15) size introduced by the surgeon. 

Where the stricture is very narrow at the start, and especially if 
very tortuous, this plan will sorely tax the operator's patience ; and in 
those cases where it rapidly contracts between the sittings, it may have 
to be given up. In such cases, the writer, when formerly engaged in 
surgical practice, made it a rule to start the treatment by continuous 
dilatation, and afterward resort to the interrupted. This plan succeeds 
admirably in many bad cases, and by a patient trial of it, cutting 
operations are seldom required. 

By continuous dilatation the operator brings a new element into his 
treatment, and the continual, steady pressure of the face of the stric- 
ture against the retained bougie, soon leads to the establishment of 
important changes in the inflammatory or cicatricial tissue entering 
into the formation of the stricture. 

The patient is put to bed after a warm bath, and twice a day 10 
grains of boric acid are administered after food. This drug is an im- 
portant branch of the treatment, as it renders the bladder perfectly 
aseptic, and robs the method of many of its objections. It occurred 
to the writer to recommend it after observing the changes which 
often occur in the urine some days after an instrument has been tied in. 



798 STRICTURE OF THE URETHRA. 

So prepared, and every attentien to the patient's health and kidneys 
having been paid, a soft gum-elastic catheter is passed through the 
stricture, which it must fit loosely. It is tied in and allowed to re- 
main for twenty-four or forty-eight hours, when a larger one is sub- 
stituted for it. This is again changed at the end of two or three days, 
and so on until the full size is reached. The bone end of the catheter 
should be removed and a small plug of wood inserted into the calibre 
of the instrument. The catheter should be kept free of the neck of 
the bladder ; it may be pushed home as the urine is required to be 
drawn off every four hours ; after this is accomplished, it may be with- 
drawn for one or two inches, so as not to cause needless irritation to 
the neck of the bladder. The plug of wood must be carefully inserted 
each time into the end o*f the instrument. 

This plan as just described is followed by relapse so often that it is 
now seldom carried out ; but if it be discontinued as soon as, say No. 7 
can be passed, the treatment then can be carried out by further inter- 
rupted dilatations by polished solid metal sounds. Its great value is 
in starting this treatment in the case of very fine or tortuous strictures, 
where the passage of small-sized rigid instruments is very dangerous 
from their liability to form false passages. 

The plan of treating strictures by rupture or forcible dilatation is 
carried out in two ways. An instrument consisting of two blades 
folded together, so as to take the shape of an ordinary sound, is passed 
into the urethra through the stricture, when the blades or lateral 
halves are slowly caused to separate by turning a screw in the handle. 
The stretching ruptures the stricture, as stricture tissue will not yield 
to any appreciable extent. The operation is carried out at one sitting, 
lasting over fifteen to thirty minutes. 

A speedier plan is that sometimes known as divulsion, in which a 
somewhat similar instrument is used, but the force is suddenly applied 
by thrusting a wedge or rod of metal between the parallel halves of 
the dilator. The sudden expansion of the blades splits or rips open 
the fibrous tissue of which the stricture is composed. 

Both methods are very dangerous, being liable to be followed by 
the worst complications, and w 7 hen immediately successful are gener- 
ally followed by speedy relapse. 

The writer has witnessed the practice of a plan in favor with the 
old school of surgeons, which, though dangerous and objectionable, 
nevertheless sometimes gave brilliant results in the treatment of recent 
soft elastic strictures. He tried it once himself many years ago, and 
was surprised to find how easy and successful it was. A moderately 
wide stricture, say one admitting a No. 6 or 5 English solid tapering 
or bellied sound, is dilated by the next size, and one such instrument 
after another is passed, the force gradually increasing, though never 
amounting to anything like strong pressure upon the handle, until a 
No. 12 is passed at one sitting. The number of strictures to which 
such heroic treatment would be applicable must be very limited. 



STRICTURE OF THE URETHRA. 799 

Urethrotomy is the operation of cutting through the stricture. This 
is done internally from the urethra, or externally by cutting down 
upon it through the skin from without. 

Internal urethrotomy is applicable to strictures near to the meatus, 
to those which contract rapily after dilatation by bougies, to dense 
cartilaginous or narrow bridle strictures which cannot be dilated with- 
out the use of a force being applied which is not safe, and to strictures 
in patients subject to rigors and urethral fever of a severe type. 

A great variety and number of ingenious instruments are used, each 
operator selecting one which carries out some requirement that he con- 
siders essential to success. These may be divided into two classes — 
i. e., those designed to sever the stricture from before backward, and 
those which are first passed through the stricture, which is then divided 
as the instrument is withdrawn, cutting from behind forward. 

In very narrow strictures of cartilaginous hardness the former kind 
of instrument is employed. A filiform guide-bougie is first passed 
through the stricture into the bladder. Upon this a hollow sound is 
introduced through the narrowed part, and by means of a shielded 
blade, guided upon a contrivance attached to the halves of this sound, 
the narrow stricture is divided to the required depth as the blade is 
pushed against the stricture toward the bladder, cutting from before 
backward. 

Where the stricture can be dilated to the size of a No. 5 instrument, 
the urethrotome of Thompson, Civial, or Otis, is passed through it, 
and as the instrument is withdrawn the concealed blade is caused to 
incise the narrowed part for its entire length, the depth of the inci- 
sion and the " tautness " of the parts being regulated by various 
mechanical contrivances designed for the purpose. The stricture must 
be divided through its entire depth, but care must be taken to leave 
intact the healthy vascular or erectile tissue lying external to it. In 
using Thompson's urethrotome the operator gets great assistance by 
feeling the resistance of the tissues and the progress of the blade, by 
grasping the penis from the outside with the fingers of the left hand. 

After the operation of cutting, a large solid metal sound (No. 14 
English) is put into the urethra, and permitted to find its own way 
into the bladder by gravitation. This gives a practical proof of the 
completeness with which the stricture has been divided, and should 
the sound fail to enter the bladder without pressure a second incision 
of the parts may be considered advisable. Upon withdrawal of the 
sound the largest sized metal catheter is inserted, and the bladder 
very thoroughly emptied of all urine. It is.a mistake to attempt to 
tie in a catheter. The patient is placed in bed, gets a morphine sup- 
pository and abstains from drinking liquids, and is kept very warm so 
as to encourage the action of the skin, while a few bits of ice are used 
to relieve thirst. In six, eight, or ten hours, when he can hold his 
urine no longer, he is placed in a hot bath and permitted to mictu- 
rate. Rigors are to be anticipated by a full opiate, whiskey, and 



800 



STRICTURE OF THE URETHRA. 



quinine, and the bowels, which should have been purged before opera- 
tion, are allowed to remain locked up for the first four days. Harri- 
son always combines external with internal urethrotomy in order to 
establish thorough drainage of the wound, and thus prevent rigors and 
sepsis. 

The following combination may be used to prevent rigors and fever : 

R . — Quininae sulphatis . . gr. vj. 

Pulv. ipecac, et opii. gr. xij. 

Acidi borici gr. v. — M. 

Make six of these powders. 

S. — One to be given immediately after the operation, in a tablespoonful of 
whiskey, and repeated in three hours and again in six hours if necessary. 

The following may be given where large doses of quinine cannot be 
tolerated : 



R . — Morphinse hydrochlor. 
Antipyrin. 
Cocaina? hydrochlor. 
Aquse chloroformi . 
S. — A dessertspoonful to be taken ever 



. gr.j. 

. gr. xl. 

. gr.vj. 

. ad giij.- 

two hours in a little water. 



M. 



Hemorrhage may be troublesome at any time within a week after 
the operation, and is especially liable to come on after erections if the 
incision has been too deep. If from the deep portion of the urethra, 
firm pressure and ice-bag or the crutch of Otis may be used. If from 
the penile portion of the canal a firm catheter or lithotomy tube may 
be passed, and a bandage placed around the penis so as to compress 
the bleeding surface against the instrument until sjme effort is made at 
repair. 

Extravasation of urine, urethral or septic fever, pyemia, cystitis, 
epididymitis, urethritis, or kidney trouble, must be dealt with promptly 
if they show themselves. 

About the seventh day the patient, in a warm bath, should have 
a well lubricated, soft gum-elastic bougie (No. 12 English) passed 
through the urethra, and he should be confined to bed until this period. 
About every three days for the next fortnight will suffice for the 
passage of the bougie, and at the conclusion of the treatment the 
patient is taught to do this himself, the after-management being ex- 
actly the same as if the operation of interrupted dilatation had been 
carried out. 

Where long-standing bladder troubles cause fetid or ammoniacal 
urine and pus to trickle over the wound, the operation of draining the 
bladder by means of a perineal wound is sometimes considered, but the 
very marked and reliable effects of boric acid when given internally 
will nearly always do away with this necessity. 

In external urethrotomy the stricture is reached from without, and 



STRICTURE OF THE URETHRA 801 

there are various operations to suit the requirements of the different 
cases. The cases in which the operation is indicated are those gener- 
ally associated with urinary fistula and a dense unyielding stricture, 
and those instances in which a portion of the urethra is practically 
obliterated by a tortuous narrow stricture, through which it is impos- 
sible to get any instrument toward the bladder, and in which internal 
urethrotomy would be highly dangerous or impossible. 

When an instrument can be introduced through the stricture into 
the bladder, Syme's operation is the one usually selected. A staff, 
grooved upon the convexity of its curve, which is about the size of a 
So. 2 English catheter, is passed through the stricture into the bladder. 
The groove is in the middle of the curve, and this ends abruptly in a 
broad shoulder which marks the beginning of the anterior portion of 
the staff, which is about the size of a No. 12 English from the shoulder 
to the handle. With the patient in the lithotomy position, and the 
narrow grooved part of the staff through the stricture, the broad 
shoulder being held against its face, the operator cuts down upon it 
from without by a median incision, enters the groove with his knife and 
divides the stricture in its whole extent, after which a catheter is passed 
upon a probe acting as a guide into the bladder. A fine gorget may 
be used to incise the urethra in the direction of the bladder. A catheter 
is tied in for the first three or four days, and a bougie or sound passed 
every second or third day until the perineal wound heals. 

Wheelhouse's method is the one generally selected when it is found 
impossible to get any guide or instrument into the bladder through the 
stricture. With the patient in the usual lithotomy position, a staff is 
passed down to the stricture and held there, the button-like point of 
the staff bearing down against the face of the narrowed tunnel. A 
median incision is made down to the staff, and the urethra fully divided 
for nearly an inch. The edges of the wound in the urethra are held 
apart by sutures or forceps, and after careful sponging a search is made 
for the opening of the mouth of the stricture. When this is obtained, 
a grooved director is passed through it into the bladder, and upon this 
instrument the tortuous, narrow stricture is divided to its whole extent 
by a narrow knife or gorget. A large catheter is then passed down the 
urethra, guided into the incised part, and pushed gently into the bladder, 
where it is retained, as in Syme's operation. 

When it is considered advisable to open the urethra behind the stric- 
ture, the operation of perineal section is selected in those cases where it 
is impossible to pass any guide into the bladder. 

In the lithotomy position the operator places his finger in the rec- 
tum upon the tip of the prostate. A sharp-pointed bistoury is plunged 
into the middle line of the perineum, half an inch in front of the 
anus, with its back toward the bowel, and aims at opening the dis- 
tended urethra at its membranous portion, just at the tip of the pros- 
tate. When this has been accomplished, a grooved probe is passed 



802 STROPHULUS — STY. 

through the wound into the bladder, and upon this a tapering gorget 
is guided. 

When the bladder has thus been successfully reached, two ways are 
open for dealing with the stricture — a probe passed into the wound may 
feel for the posterior opening of the stricture, through which it may be 
be passed, and which may then be divided from behind forward, or an 
an instrument may be inserted down the urethra, and its point cut 
upon until it appears in the wound. When this has been achieved, a 
large catheter should be passed down the urethra and guided into the 
bladder, and the most patient dilatation by the passage of sounds must 
be kept up long after the healing has been established, as such stric- 
tures are very prone to contract. 

Sometimes it is only possible to effect the entrance into the bladder 
from behind the stricture without being able to deal with the latter, 
and it is astonishing to find afterward how easily a narrowing, which 
had foiled all attempts at catheterization, can be made to yield after a 
few days' rest following perineal section. Shield -successfully sutures 
the urethral wound after perineal section. 

Excision of the strictured portion of the urethra has been tried, but 
with indifferent results. Recently Wolfler has found that the mucous 
membrane was reproduced upon a urethra from which he had excised 
an innodular stricture. He uses the mucous membrane obtained from 
the " stomach of the frog, the bladder of the rabbit, or from the 
oesophagus of the pigeon, which are all easily separable from the mus- 
cular layer of the animal, and which all adhere in the human subject, 
and when properly placed retain their vitality." 

Electrolysis (3 to 5 milliamperes) has been employed for the cure of 
stricture, but all authorities of weight are agreed in pronouncing it to 
be unsatisfactory, many regarding it as a failure. 

Fort uses linear electrolysis by means of a current of 20 to 40 milli- 
amperes, and an instrument constructed like a Maisonneuve's urethro- 
tome. The results are far from satisfactory. 

STROPHULUS. 

The treatment of this affection should be that of a mild form of 
lichen in infants. Most authorities regard it as identical with lichen, 
the treatment of which is given upon page 449. 

In the infant the affection generally yields rapidly to improved feed- 
ing and aperients, with some mild alkali, as fluid magnesia. Locally, 
any mild unirritating sedative, like the oxide of zinc, dusted freely 
over the part, does best. 

STRUMA— See Scrofula, page 773. 
STY. 

In the early stages epilation will generally at once remove the 
trouble. By plucking out the eyelash, any matter that may have 



SUFFOCATION — SUNSTROKE. 803 

already formed is thus left free to discharge itself through the minute 
opening. If matter has not formed, this method may prevent it. A 
needle dipped in pure carbolic acid may be applied to the spot after 
the removal of the hair. Nitrate of silver . is generally used for this 
purpose, but it is very painful, and may increase the swelling. 

Poultices in the neighborhood of the eye are very unsatisfactory. 
Hot fomentations are less objectionable. A very weak spirit or car- 
bolic lotion is preferable, though it is not advisable to cover this in 
with oiled silk. The relationship of the sty to boils gives the indica- 
tions for general and local remedies, and poultices or any other appli- 
cations, especially if moist and warm, have a tendency to multiply the 
the local gatherings of pus, if the retained vapor arising from such 
applications is not speedily permitted to evaporate. Puncture with 
the point of a fine narrow-bladed tenotomy knife or cataract needle 
generally gives immediate relief when matter has formed. 

A weak ointment of the yellow oxide of mercury (6 grains to 1 
ounce) is the best after-treatment in all cases, and it appears to prevent 
further formations if properly used. 

The following oitment may be used with benefit when the condition 
threatens to return : 

R . — Cocainse purif. gr. v. 

Hydrarg. oxidi rub gr. iij. 

"Vaselini alb . . . gvj. — M. 

S. — To be smeared over the margin of the affected lid three times a day. 

SUFFOCATION. 

The treatment of this condition will depend upon the cause, which 
must, of course, be immediately removed. Foreign bodies in, or con- 
strictions around, the air-passages call for instant remedying. Trache- 
otomy may be resorted to where the obstruction is above the larynx 
and cannot be removed. The various methods of performing artificial 
respiration are described under the article upon Drowning, page 199. 

SUNSTROKES. 

Instanct transference to the shade, with removal of outer clothing 
and all constrictions about the neck, throat, and chest, is the first step. 
In the pure syncopal or exhaustive variety of insolation this may be 
all that is necessary, with bathing of the face and hands in cold water 
in mild cases ; but where the symptoms are pronounced the cold douche 
should be freely used, and in cases of hyperpyrexia life can only be 
saved by a free use of it. In such cases the patient must be treated 
upon the spot where he falls by the liberal application of cold water, 
in the form of douche, or cold affusion, the object being to rapidly 
reduce the temperature of the body by extracting the heat from it by 
cold water or ice, as in a case of hyperpyrexia in acute rheumatism. 



804 SUPPRESSION" OF URINE. 

The temperature should not, however, be permitted to fall too low. A 
reduction from, say 110° F. to 101° or 102° is better than a reduction 
to 95° or 90°, as some recommend. If there be evidence of great car- 
diac failure, stimulants may be required ; but they should be used with 
great caution, and the horizontal position rigidly maintained. If re- 
moval in such cases is necessary before the urgent symptoms have 
subsided, it should be accomplished upon a stretcher. 

Where the symptoms continue, and repeated affusion is necessary to 
keep the temperature from rising, the thermometer should be kept in 
the rectum, so as to enable the physician to keep the body heat a little 
above the normal. Artificial respiration may be needed, and nitrite 
of amyl or chloroform may be used if convulsions occur. 

Copious enemata of iced water have occasionally been found useful, 
and they may be resorted to in conjunction with cold affusion or the 
cold bath, or used alone where from any reason these cannot be 
employed. 

After the hyperpyrexia has been combated, symptoms are to be 
treated as they arise. Headache may be relieved by the ice-cap, by 
sinapisms or blisters behind the ears or over the occipital region or 
or neck ; constipation by smart saline purgatives, and any remaining 
febrile temperature by small doses of antipyrine, to which digitalis and 
quinine may be added. 

Strong purges and bleeding are seldom indicated, and they may do 
serious harm. The same remarks apply to opium or hypodermic injec- 
tions of morphine. In the after-treatment no animal food should be 
given for days, and absolute rest in bed must be maintained. 

Meningitis and other troubles, should they follow, are to be met by 
appropriate remedies. As recovery is often imperfect, and followed by 
an irritable condition of the cerebral centres, bromides will be indi- 
cated, and in some cases, owing to the increased susceptibility to heat, 
removal to a cold or temperate climate may be imperative, with avoid- 
ance of mental work and all sources of worry for a considerable period. 
Prolonged muscular exercise is also to be guarded against, and the use 
of alcohol strictly forbidden. 

SUPPRESSION OF URINE. 

If this be caused by the degeneration of the kidney, as it sometimes 
is, in the last stages of renal affection, the proper treatment will be 
that of Bright's disease, page 75. 

If the suppression follows the impaction of a calculus in the ureter, 
this must be promptly treated by the various measures mentioned upon 
page 788, under Stone in the Kidney. 

When suppression follows the internal use of such agents as can- 
tharides and chlorate of potassium, etc., the measures mentioned under 
Strangury will be indicated. 

When the condition depends upon active congestion of the kidneys, 



sycosis. 805 

the result of a sudden exposure of the heated body to a low tempera- 
ture, the proper treatment will lie in the use of those remedies calcu- 
lated to restore the equilibrium of the circulation, as hot baths, dia- 
phoretics, warm poultices, sinapisms, or cupping to the loins. Where 
suppression follows urethral injuries or operations upon the urinary 
tract, similar measures may be employed. In every case the treatment 
will resolve itself into a removal or amelioration of the cause. When 
the anuria fails to respond in a short time, uraemia comes gradually 
on, and the remedies mentioned in detail under Bright's Disease, upon 
page 73, will be demanded. 

These may be summarized as agents which will hasten elimination 
of urea and other products by the bowel and skin, as saline cathartics 
— i. e., sulphate of magnesium in full and oft-repeated doses, the 
blanket, hot air, vapour or hot water baths, the hot pack, pilocarpine, 
etc. ISTo reliance whatever is to be placed upon diuretics which may 
seriously intensify the mischief. 

In acute cases, as in active congestion from a chill, alone or associ- 
ated with pneumonia, or with congestion of the lungs, or acute bron- 
chitis, a free blood-letting, by opening a large vein and making a rapid 
impression upon the circulation, may save life. In less urgent cases 
wet cupping over the kidneys is recommended. The writer, however, 
would advise blood-letting from the arm if the case looks so serious as 
to at all justify the removal of blood. 

SUPPURATION— See Abscess, page 12. 

SWEATING-— See Perspiration, Excessive, page 615. 

SYCOSIS. 

There is great diversity of opinion about the best treatment for this 
troublesome affection. This to a large degree arises from the different 
views held as to its pathology. At present the great majority of 
authorities maintain that the common form of sycosis is not in any 
sense a parasitic affection ; others there are who hold that it depends 
upon the presence of a microphyte or coccus. The writer, merely from 
watching closely the clinical features of the disease, has long satisfied 
himself of the parasitic nature of the common form of sycosis. All 
are, however, agreed in recognizing a variety of sycosis, which is really 
a ringworm of the beard or chin, and produced by the spores of 
trichophyton tonsurans. 

The treatment of the common form will be first dealt with. Unna, 
who maintains that this is owing to cocci, nevertheless states that the 
greatest success will be obtained by treating it as a fu.runculosis. 

The first points to settle are whether shaving, clipping, or epilation, 
or allowing the beard to grow is the best practice. The writer advises 
that if the case be seen early, close shaving of the part should be car- 
ried out ; if there be much irritation, shaving should not be attempted, 



806 sycosis. 

but the hairs should be clipped close with great care and nicety by a 
sharp-pointed pair of good scissors. If the physician is in doubt as to 
whether shaving or clipping is the best, better let him lean to the 
clipping. The hair should never be allowed to grow. 

Epilation is much abused, and in the early stages of the disease does 
harm. It should not be applied to the hairs indiscriminately, if done 
en masse great irritation and n'o benefit follows. Only those hairs 
which are showing signs of being loosened in their follicles should be 
removed, and these should be seized singly in the forceps and removed 
every day. The first step in the treatment will be the removal of all 
crusts or scabs before even clipping or epilation can be performed. A 
starch poultice is undoubtedly the best application for this purpose 
when it is properly made. Brocq advises that the starch for a poultice 
be first blended thoroughly with precisely the proper quantity of tepid 
water to form a paste. Boiling water is poured on to the paste, and 
the mixture left upon the fire for about one minute, being very briskly 
stirred to ensure its being thoroughly homogeneous. It may be then 
spread upon some soft, flexible fabric, and applied to the part. A little 
boric acid (10 per cent.) added to the dry starch, is a great improve- 
ment. 

After the removal of the poultice the part may be smeared over 
freely with lard and oil, and another poultice or a good sponging with 
hot water may be applied in order to clear away all crusts, after which 
the hair may be clipped and any loose bristles removed by the forceps. 
In this way most of the purulent points will be evacuated ; any others 
may be incised with the point of a sharp lancet. The application from 
which the writer has obtained the most benefit is a carbolic oil (1 : 5 or 
6). A little perseverance with this will save the physician from trying 
the innumerable formulae which are published for the specific cure of 
sycosis, many of which are, no doubt, valuable, but all of which are 
useless unless patiently applied for considerable periods. 

Jackson advises the internal administration of -^ grain doses of the 
sulphide of calcium every one or two hours, and the application of 
Lassar's paste with salicylic acid. He also advises " curetting," but 
this should be very seldom resorted to. 

Unna in severe cases, applies a carbolic-mercurial, or a resorcin- 
plaster muslin to be worn constantly, or when night treatment only can 
be carried out he applies all night a zinc-sulphur salve muslin, epilat- 
ing every morning, and touching the suppurating follicles individually 
with a 5 per cent, resorcin spirit, corrosive sublimate, or carbolic acid. 

Rosenthal claims that the following ointment acts as a specific in 
the great majority of cases : 



-Acid, tannici .... 


• 3J SS 


Sulphur lact 


• 3iij- 


Zinci oxidi .... 


. ^ivss. 


Pulv. amyli .... 


givss. 


Vaselini 


. 3jss.— M 



sycosis. 807 

The following modification of this is also recommended — tannic 
acid 23 grains ; lactate of sulphur, 48 grains ; vaseline, 1 ounce. 

Any antiparasitic agent applied in dilute solution will effect a cure. 
Thus ointments of creasote (1 : 9), eucalyptus (1 : 5), boric acid (1 : 7), 
salicylic acid(l : 28), carbolic acid (1 : 19), chrysarobin (1 : 25), iodide 
of sulphur (1 : 16), tar (5 : 7), sulphur (1 : 5), mercury (1 : 2), ammo- 
niated mercury (1 : 10), calomel (1 : 6), nitrate and oxide of mercury, 
or ointments containing ichthyol (10 per cent.), oleate of mercury (15 
per cent.), resorcin (20 per cent.), pyrogallic acid (10 per cent.). 

If, during the use of these agents irritation arise, the ointment 
should be stopped immediately, and plain zinc ointment or the lini- 
mentum calcis, be applied in its stead. 

All those who have had much experience in the treatment of the 
disease insist upon the necessity of constitutional remedies, as cod-liver 
oil, iron, quinine, and tonics, and the correction of any departure from 
the standard of health. 

In the treatment of the parasitic sycosis the remedies applicable to 
ringworm of the scalp are indicated. (See under Tinea.) Here, as 
in the common form of the disease, nothing can be done until, by 
fomentations and starch poultices, all crusts are removed and irritation 
subdued. The next step will be clipping of the hairs, and epilation of 
those evidently diseased or suspected. 

The further treatment will consist in the steady and patient applica- 
tion of antiparasitic remedies, as mentioned upon the previous pages. 
These must, however, be used in more concentrated form, and mild 
ointments, as lard or almond oil, can be applied occasionally to subdue 
the irritation which they generally produce. 

Chrysarobin is unquestionably the most valuable, but owing to the 
irritation of the face, and the discoloration following its use, it can be 
of little service in this affection, Creasote ointment (1 : 9) is an excel- 
lent application. The student will almost despair of making a begin- 
ning in the treatment of this affection if he ponders over the hosts of 
formulas given in the text-books or scattered through the journals, 
most of which are vaunted as specifics. Success in the practical treat- 
ment of this and other allied affections will consist in the physician 
making himself thoroughly acquainted with the effects of a few good 
remedies upon the different kinds of skins. By degrees he soon comes 
to know the strength of the application suitable in each case. A weak 
ointment of iodide of sulphur is one of the most certain agents we 
possess, but it is generally worse than useless owing to the careless way 
in which it is prepared by the chemist. It should not be used for 
several days after it has been made up. Fifteen or 20 grains to the 
ounce will be strong enough for sycosis. 

Citrine ointment stains the skin less than the iodide of sulphur 
ointment. 

The oleate of mercury (5 per cent.) is a workable and efficient 
destroyer of the germs which cause the disease. 



808 SYMBLEPHARON — SYNCOPE. 

Greasy preparations are better than watery or spirituous solutions 
as these latter will not find their way down into the deep parts of the 
hair follicles where the parasite burrows, and for this reason the oint- 
ments should be applied with friction after epilation. 

For the other various agents which may be used in this affection see 
under Tinea. 

SYMBLEPHARON, 

Or adhesion of the eyelid to the eyeball, exists in so many degrees 
and in so many forms as to prevent any definite line of operation 
being applicable as a routine treatment. In minor degrees the condi- 
tion can be easily dealt with by severing the adhesion or band by 
scissors. In severer forms, where the adhesive surfaces cover a large 
extent of the lid, they must be carefully dissected from each other 
and a transplantation of a small piece of mucous membrane from the 
lips or labia effected. The conjunctiva of the rabbit has been grafted 
successfully. Subsequent adhesion of the dissected surfaces may 
sometimes be prevented by turning the conjunctival flap upon itself 
and retaining it in this position by sutures. 

SYNCOPE. 

Though this is but a symptom of some more serious condition requir- 
ing active treatment, the first thing to be done is to attend to the 
symptom without delay. The patient must be placed in the horizontal 
position, with his head low — a little lower than the level of his body. 
All constrictions about his neck should be removed without delay, and 
a current of pure cold air should be allowed to blow over him when 
possible. If swallowing is for the time impossible a dash of cold water 
in the face is a powerful reflex stimulant to the heart, and may be 
safely resorted to. Ammonia, smelling salts, or strong acetic acid to 
the nostrils, with flapping the hands by a wet cloth, may be tried. 
Where the attack withstands this, and the patient is still unable to 
swallow, ether or ammonia (sal volatile, 1 part ; water, 5) may be 
injected hypodermically, or whiskey and water, brandy, wine, or any. 
available stimulant may be injected into the rectum. 

As soon as the power of swallowing returns stimulants may be given 
by the mouth. 

In desperate cases ammonia, or ether, or whiskey, may be injected 
directly into a vein, and electricity — the interrupted current — applied 
to the phrenic nerve or heart. Nitrite of amyl inhalation may be 
tried. Where hemorrhage has been the cause of the fainting, some- 
times success may follow the rapid elevation of the lower extremities 
and the application of a rubber bandage to drive the blood which is 
contained in them toward the heart. Where these measures fail trans- 
fusion may be resorted to without delay. Artificial respiration, fric- 
tions, electric shocks through the arms, and the application of hot 



SYNOVITIS. 809 

sinapisms may be tried while the more serious operation of transfusion 
or intravenous injection of warm, weak, saline solution is being pro- 
ceeded with. (See under Collapse, page 133.) 

SYNOVITIS. 

Under Joint Diseases and under Hip- and Knee-joint Diseases the 
treatment of the chronic forms of this affection is detailed, when the 
diseased action has eventuated in pulpy degeneration or in more or less 
disorganization of the joint. 

In acute synovitis absolute rest must be secured for the inflamed 
joint. This may be done in various ways, as by the use of splints, 
sand-bags, etc. Such appliances, however, are not to interfere with 
the application of remedies about to be mentioned. 

Cold applications, either in the form of evaporating lotions, or, what 
is much better, ice applied freely around the joint, is the most successful 
of all treatments. Leeching may be resorted to when the pain and 
high tension do not rapidly yield to ice-bags applied around the joint. 
Upon an inflamed knee-joint a dozen or more leeches may be placed, 
and not only are the local, but sometimes the constitutional symptoms 
are rapidly relieved thereby. If grateful to the patient, hot fomonta- 
tions may follow the local blood-letting. 

Free saline purgation by sulphate of magnesia, followed by a 
diaphoretic containing small doses (y 1 ^ grain) of tartar emetic, at short 
intervals, is the best constitutional treatment is sthenic and traumatic 
cases occurring in the robust. 

The following mixture may be administered : 

&. — Magnesii sulphatis ^ij. 

Antimonii et potassii tart gr. ij. 

Tinct. aconiti TTL v. 

Syr. aurantii gj. 

Aquse menthse piperitse ad ^xvj. — M. 

S. — Two tablespoonfuls to be taken every second hour. 

In those instances where a distinct rheumatic element is present 
large doses of salicylate of sodium should be given ; and where gout 
figures in the causation colchicum may be safely prescribed, with a 
padding of absorbent wool around the joint, wJiich should then be 
enveloped in oiled silk. 

Opium internally must be given with caution; but when severe 
pain and high constitutional disturbance are present it cannot be with- 
held. Fifteen grains of Dover's powder, with 2 grains James's powder, 
may be given every six or eight hours. In synovitis in syphilitic 
patients a few full doses of blue mass, followed by a smart saline 
purge, may be used before putting the patient upon large doses of the 
iodide of potassium. 

Where a large quantity of fluid has been poured out into the joint, 

52 



810 SYPHILIS. 

and there is danger of disintegration occurring from the very high ten- 
sion, no harm can come from aspiration, followed by ice and rest. 

As soon as the acute symptoms have subsided prolonged rest may do 
harm, and if the joint has passed into the chronic stage a reversal of 
the treatment may be the first and only line of practice followed by 
relief. If much fluid remain the joint after the subsidence of the pain 
and local heat, counter-irritants are to be employed. Small blisters 
may be applied in three or four places over a large joint like the knee, 
or the actual cautery may be lightly pressed against the skin in a few 
places. These are also the most important agents to use in the treat- 
ment of subacute or chronic synovitis. Combined with them, massage 
and friction with stimulating liniments, or painting of the joint with 
strong iodine, may be tried. 

When the fluid resists these measures it may be drawn off by the 
aspirator, and a soft, pure rubber bandage applied for some days. 
Indeed, it is sometimes wonderful to observe the rapid effect of a rub- 
ber bandage over a distended knee-joint when the aspirator has not 
been employed. Some cases of hydrops articuli yield to this. In other 
cases strapping by adhesive plaster- spread upon some strong fabric 
serves the same purpose, provided the plaster be removed and reapplied 
at short intervals as the swelling diminishes. Scott's dressing or a mild 
mercurial preparation spread upon lint may be applied to the joint 
under the strapping. By these means much fluid and even thickening 
of the synovial membrane may be got rid of by the assistance of pas- 
sive motion and gentle exercise of the joint and the internal adminis- 
tration of iodide of potassium. 

When suppuration occurs in the joint there need be no time lost in 
the trying of these remedies. The only thing open to the surgeon in 
such cases is to make at least two free incisions into the joint in the 
most dependent aspect, wash it out thoroughly by a stream of warm 
antiseptic solution, and insert a drainage-tube under a liberal supply 
of antiseptic dressing. The limb should be placed in the most desirable 
position for ankylosis, though the hope of a movable joint is not to be 
altogether abandoned. 

Excision and the various operative and constitutional measures ap- 
plicable to very chronic cases which have resisted all the above plans 
of treatment and gone on into pulpy degeneration are described under 
Joint Disease. * 

SYPHILIS. 

The treatment of the local sore or chancre will be first considered. 
Considerable difference of opinion exists as to the proper line of treat- 
ment to be adopted. Some authorities maintain that no good whatever 
can come from any attempt to destroy the poison at its point of entrance 
into the body, as it has already, by the time the patient comes under 
notice, been multiplying itself in the blood. Others affirm that local 



SYPHILIS. 811 

abortive treatment may be successful. Few, however, will be found 
to have any faith in the influence of any local abortive treatment when 
the sore has once shown unmistakable evidence of induration. Yet 
even here the application of a caustic judiciously applied, as the strong 
liquor hydrarg. nit. or fuming nitric acid, cannot possibly do any harm 
and even at this stage of the disease the question narrows itself down 
into whether the surgeon is to do nothing at all in the way of destroy- 
ing the sore or whether he is to adopt a line of practice which, though 
almost certainly useless, is not in any way harmful. As a matter of 
routine, even at this late stage it may be well to cauterize the surface 
of the chancre. 

When a sore is seen at an earlier stage, before induration appears, 
the question is different. Hutchinson lays down the law that if the 
patient be seen at any time within a fortnight after contagion with a 
non-indurated sore it should be completely destroyed. The shorter the 
period, the greater the hope of success. The applications just men- 
tioned may be used, but in such cases the excision of the sore by means 
of the galvano-cautery is the best practice. 

After its destruction, or in those cases too far advanced for cauteriza- 
tion, a host of remedies may be employed. Perhaps the best routine 
agent to use is the black wash, applied on lint and changed frequently. 
It is, no doubt, inferior to iodoform, which answers every indication 
perfectly, but owing to its easily recognized and penetrating odor this 
latter must often be laid aside for the old-fashioned black wash. Where 
the sore is inside a long prepuce this objection hardly maintains, as 
there is little chance of its volatilization or the escape of its odor. 

Where the sore refuses to heal under this treatment it may be occa- 
sionally touched lightly with the nitrate of mercury solution, or if any 
marked tendency to spread is noticeable the fuming nitric acid should 
be at once freely resorted to. Phagedena must be met by the agents 
detailed under Gangrene (Hospital). In every case of chancre the 
most rigid attention to absolute cleanliness is necessary. 

The vast majority of cases heal up under iodoform or black wash. 
Where there is much moisture about the sore calomel is an excellent 
remedy when freely dusted over it. Where the sores are placed upon 
the outside of the penis much trouble may be saved by Bloxam's sim- 
ple plan of applying a small piece of the U. S. P. emplastrum hydrar- 
gyri spread upon wash-leather. In the case of female patients, cleanli- 
ness can only be obtained by the constant use of the warm sitz-bath 
twice a day. 

The constitutional treatment at this stage of the disease will embrace 
everything calculated to improve the general health : a light nutritious 
diet, abundance of fresh air, moderate amount of work and a fair pro- 
portion of exercise, and a total cessation from all indulgence in alcohol 
in every shape and form. Tobacco may be permitted, but only in 
moderation, and over-feeding and all excesses must be discountenanced. 



812 SYPHILIS. 

It is hardly necessary to state that sexual indulgence must be strictly 
forbidden. 

Mercury is the only reliable drug in syphilis. Where failure fol- 
lows, it is owing to some error in its administration. 

Many points still remain to be proven as to the time, methods of 
administration, etc., but these are being gradually set at rest by the 
researches and observations of reliable authorities all over the world. 
The first real step in advauce was made when it was demonstrated that 
in order to cure syphilis by mercury salivation is unnecessary. This 
important fact is the keynote to success in the treatment of the disease, 
and its clear recognition means more than what lies upon the surface. 
It is not merely because salivation in the old sense of the term is now 
known to be injurious to the patient, but because of what follows in 
connection with the action of the drug. This may be briefly stated in 
these words : When mercury was given in heroic doses with the view 
of causing salivation as rapidly as possible, the administration of the 
drug had to be suspended for a very considerable period, and with 
many physicians was never again resumed in the case ; we know now 
that the best results are only to be ■ obtained by very small doses of 
the remedy administered uninterruptedly over long periods. Later 
on the different methods, hypodermic, epidermic, etc., will be detailed. 

The first great question to be settled is, should the drug be admin- 
istered in the primary stage of the disease ? Some affirm that it is 
useless or even injurious. Hutchinson, in his address before the Medical 
Society of London, published in the British Medical Journal, February, 
1888, enters into this point most minutely, and his statements should 
be accepted as settling the question for all time. He says : " The 
statement which I wish to make quite clear is this : that I believe that 
it is quite possible by the early and continuous use of mercury to sup- 
press the secondary stage — in other words to make it abortive. In exceed- 
ingly few cases where it has been possible to use mercury without 
interruption in this way have I known a well characterized secondary 
eruption or a typical sore throat to occur. In cases where diarrhoea or 
sudden ptyalism has caused the course to be interrupted the success 
has been less complete ; but where the patient is careful and can bear 
the drug I may repeat that I believe that it is easily possible to prevent 
secondary symptoms." Of the truth of this statement the writer is 
perfectly satisfied by clinical observation, and he accepts the principles 
of the abortive plan without any reservation as one of the most certain 
and brilliant advances in therapeutics. 

As soon, then, as a patient presents himself with an indurated 
chancre, he should be placed upon small doses of mercury, as 1 grain 
of calomel morning and evening, 1 grain hydrarg. cum. creta, in pill, 
three times a day, or 1 grain blue mass, or -}% grain perchloride twice 
daily. 

The following combination has many advantages : 



SYPHILIS. 813 

R. — Hydrarg. cum. cretse g r -J- 

Quinina? sulph. ■ gr. jss. 

Pulv. opii gr. i. 

Ext. quassia? q. s. — M. 

Make 36 of these pills. 
S. —One pill to be taken after meals three times a day. 

In a fortnight or three weeks the chancre is markedly changed for 
the better, and the induration is greatly reduced and rapidly disappears 
as the system gets under the influence of the antidote. This treatment 
should be steadily persisted in for six or nine months, the gums being 
watched closely, and the dose diminished upon any marked sponginess 
or ptyalism. In Aix, where the closest attention is given to every 
detail that facilitates the admission of the largest amount of the drug 
into the system without affecting the gums, great care is exercised by 
the use of tooth powders and astringent mouth washes to keep the 
gums in a perfectly healthy condition. 

The writer has seen many failures in the treatment of syphilis within 
the last fifteen years, but he has been generally able to trace these to 
the nervousness of the physician, who was afraid to continue the drug 
for a sufficiently long period in sufficient doses, or to the carelessness of 
the patient who ceased to take it. Seldom, if ever, has he chanced to 
see injury done by overdoses, unless in the hands of quacks or irrespon- 
sible persons. He is, therefore, led to conclude that much greater 
injury is done by withholding the drug than by giving it too generously. 
When giving mercurials for this long period he often found himself 
anxious lest the patient might be permanently weakened by the drug, 
he has never witnessed such a result. 

He adopts in these cases a rule of his own which he ventures to hope 
will become established by the testimony of other observers who will 
try it. As long as the patient continues to gain in weight, or as long 
as he steadily keeps to his normal standard of weight, there is little 
danger to be feared from the action of the drug upon the system. 
Accurate weighings should be accomplished once a week or once in a 
fortnight in the physician's study after the patient has been taking the 
drug for several months. Under this abortive treatment the rash may 
not appear at all, or if it appears, it is so much modified as not to be 
easily recognizable. The same may be said of the sore throat and other 
phenomena. It is, therefore, advisable, if not imperative, that mercury 
should be given as soon as an indurated chancre comes under notice, 
without waiting for the appearance of the rash or sore throat. Should 
mercury be given before induration appears in the sore? In other 
words, given a sore, which may not be syphilitic, are we justified in 
waiting for changes to take place in it to settle our diagnosis before 
exhibiting mercury? This question should be easily answered. 

Hutchinson thinks that it is possible to cause abortion of the primary 
stage itself. Whether this is correct or not need not deter the physician 



814 SYPHILIS. 

from beginning small doses of mercury when he considers that such 
treatment cannot possibly do the patient any harm. 

The writer adopts the practice of beginning mercurials in every case 
of sore whose history warrants a fair suspicion of its being syphilitic, 
but he always gives a small dose, one that in ordinary cases would not 
be likely to prevent induration of the sore taking place. If full 
mercurial treatment be commenced under such circumstances, it is 
more than possible that induration in the chancre might never become 
marked, and the physician, say at the end of a month or six weeks, 
would be uncertain, or in absolute ignorance of whether he was treating 
syphilis or not. Under such circumstances he would not- be justified in 
going on with a six or nine months' course. If syphilitic, however, he 
probably w6uld find that the secondary symptoms would begin to show 
themselves soon after the cessation of the mercurial treatment, even at 
the end of the third or fourth month. By beginning in these doubtful 
chancres with a very small dose, say 1 grain of calomel every night, and 
watching closely for induration, upon the first proof of which the dose 
is to be doubled or trebled, the best thing will be done for the patient. 
By giving the small doses of mercury, before the nature of the affection 
is declared, the physician will have the satisfaction of feeling that he 
has the disease well in hand, and upon the appearance of induration 
he has but to tighten the reins. 

Hydrarg. cum creta, 1 grain three times a day, is, perhaps, the most 
frequently-prescribed dose in this country. The green iodide of 
mercury, formerly a very favored preparation, is no less frequently 
employed ; it certainly possesses no advantage over calomel or hydrarg. 
cum creta. 

The method of inunction is much in vogue as a routine treatment on 
the Continent, especially at Aix, where the usual dose is about 38 
grains of the German Pharmacopoeia ointment (1 : 3), rubbed in twice 
a day for twenty minutes over the sides of the chest and abdomen and 
inner aspects of the arms and thighs. These doses would appear to be 
better borne there than at home. Oleate of mercury or the calomel 
bath may be substituted. Where the ointment is employed, it must be 
rubbed into different parts of the body in succession, otherwise local 
imitation may supervene. It is not a satisfactory method of adminis- 
tering the drug, except in selected cases, or where the patient gives 
himself up entirely to treatment, as most of those do who go to Aix. 
Where a rapid effect is desired, as in cases of neglected syphilis, or 
where pressing brain symptoms arise in the later forms of the disease, 
this method may be selected with advantage, or wherever we wish 
to obtain the full pnysiological action of the drug, or in congenital 
cases. 

The hypodermic injection of the drug in various forms has been 
exercising the minds of many able men, and when we read of the very 
small quantity which suffices to effect a cure, one must come to the 
conclusion that our present methods are crude and open to serious 



SYPHILIS. 815 

objections. It is, however, clear that the best form for the administra- 
tion of the remedy by this route is not yet determined, though progress 
is being made. In all probability, it may become the method of the 
future for routine practice. The writer has very limited experience of 
it. Bloxam, who has injected some thousands of times, justly remarks 
that it is only by this method that the physician can form any correct 
idea of the quantity of mercury absorbed into the system. Until 
recently, he used the intra muscular injection of a solution of corrosive 
sublimate (8 grains in 1 ounce of water), and the dose was 20 minims 
once a week into the gluteal region. One thousand nine hundred and 
twenty-four injections were made. Only one case gave any trouble, 
and this was where the solution was injected by mistake into the sub- 
cutaneous tissue. 

Though these results were highly satisfactory, he found that the 
pain and smarting often lasted two or three days, and he has obtained 
better results by using a solution of sal alembroth — a double chloride 
of mercury and ammonium. The following is his formula : 

R. — Hydrarg. chlor. corros gr. xxxij. 

Ammonii chlor. pur gr. xvj. 

Aquse dest ad £ ij — M. 

This is an absolutely permanent solution, the dose of which is 10 
minims — equal to one-third of a grain of mercuric chloride. He 
states : " So far I have given over 600 injections with this solution, 
and no untoward effect has been observed. The pain is comparatively 
slight, the slightest induration following, and the effects most satisfac- 
tory, as, after two injections equalling two-thirds of a grain of mer- 
curic chloride, the physiological action of the drug was produced, and 
could be maintained by an injection once a week, while the symptoms 
of the disease, both local and constitutional, underwent most rapid and 
favorable change." 

After decided mercurialism has been established, the injections are 
to be made every fortnight only, and when the glandular and throat 
symptoms have disappeared, once a month. This is kept up from 
eighteen to twenty-three months, and the average total quantity of 
mercury used in Bloxham's cases only amounted to 6 or 8 grains of the 
bichloride during the entire treatment. 

There is still great differences of opinion about the injection of the 
insoluble salts of mercury, and reports are most contradictory concern- 
ing the untoward effects which follow. Galliot has affirmed that he 
had neither abscesses nor other accident in 4000 injections of 10 centi- 
grammes (H grains) of the yellow oxide in 15 grains of vaseline oil. 
The mercury is detected in the urine in less than twelve hours after 
the injections, which should be made deeply into the buttock. Other 
observers confirm these statements, while many report that abscesses 
and pain have been the rule. 



816 SYPHILIS. 

Calomel, oxybenzoate of mercury, and other salts, are used in the 
same way. " Gray oil " is a favorite form for injection, having been 
used first by Lang. It consists of a weak lanoline ointment of mer- 
cury rubbed up with olive oil, and contains about thirty per cent, of 
mercury. The dose is 0.2 or 0.3 c.cm. injected into the back. 

Leloir uses a third of a syringeful every nine days of gray oil, made 
by mixing 80 parts of oil of vaseline, 10 of ethereal tincture of benzoin, 
and 40 of pure mercury. Salicylate of mercury rubbed up with vase- 
line or mucilage is also highly spoken of. 

The various complications or local manifestations which appear 
during the course of the disease, as a rule, steadily disappear as we 
push the mercurial treatment, and this is all that is necessary in the 
vast majority of cases in the secondary stage. 

Rarely will it be necessary to inaugurate any special treatment for 
the skin eruptions. When these occur about the face, so as to make 
it highly desirable to hasten matters, a mild mercurial ointment, as 
calomel or white precipitate, 20 grains to 1 ounce lanoline may be 
used. Where the skin eruption is very formidable the calomel bath 
may be resorted to, the patient sitting upon a cane-bottomed chair, or 
with his body in a chamber devised for the purpose. As he receives a 
vapor bath calomel is sublimed by the heat of the lamp which boils 
the water, and it is deposited in fine dust over the surface of his skin, 
after which he lies down in dry blankets. The Turkish bath during 
the mercurial course is also believed to hasten the disappearance of the 
rash. 

Mucous patches on the throat and mouth, and about the vulva and 
anus, though they yield in time to the steady use of the internal mer- 
curial, have their disappearance hastened by a light touch of the solu- 
tion of the nitrate of mercury, and the writer has often applied this to 
the tonsils. Warts upon the tongue may be similarly treated in these 
cases, as any form of local irritation will greatly aggravate matters. 
Smoking must be strictly forbidden. Where the ulcers are deep a 
little of the powdered iodoform may be blown into them with the 
insufflator. This substance may be dusted over condylomata, but a 
mixture of calomel and oxide of zinc answers very well. 

All through the mercurial course diarrhoea is to be avoided, and 
for this reason a small quantity of Dover's powder or laudanum is to 
be combined with the mercury when any tendency in this direction is 
observed. When rapid action is desired the patient should be advised 
to give himself up to the treatment, and either to remain in bed or 
in a warm room, as free exposure to the air retards the action of the 
drug, probably by hastening elimination. 

The method of continuous dosage (notwithstanding the wide-spread 
popular belief that mercury makes the patient liable to catch cold) 
may be safely carried out without any risk following the free ex- 
posure of the body to the ordinary variations and vicissitudes of the 
weather. 



SYPHILIS. 817 

At the end of six months of this mild continuous treatment, though 
the patient may feel and look to be in remarkably good health, if the 
mercurial be entirely suspended a faint delayed secondary eruption 
may for the first time show itself in a week or two. The writer has 
never observed this, as he always insists upon a continuance of the 
drug for a longer period in a greatly diminished dose. Thus from the 
fifth to the ninth month, if all has gone on well, one grain of hydrarg. 
cum creta or one grain of calomel may be all the drugs required each 
day. 

Some physicians make it a rule to stop the treatment entirely for 
longer or shorter periods, to resume with the dose as before or with a 
larger dose. This may be necessary when the drug begins to tell at 
any stage of treatment, but as a rule the best results will be obtained 
by a steady and continuous administration of the remedy in such doses 
as are not likely to necessitate pauses. 

As already mentioned, the writer's plan of making accurate observa- 
tions upon the patient's body-weight will assist in this question. It 
will be wise to suspend the drug for a time when loss of weight is 
observable. 

Tonics maybe used in the later months of treatment with great 
benefit, and in the intervals during the suspension of the mercurial. 
They are sometimes used in the early stages too freely to the detriment 
of the patient. Cod-liver oil often comes in well in the late stages in 
thin subjects. The following may often be used with advantage at 
this stage : 

R .— Tinct. podophylli (1 : 60) giv. 

Tinct. quassise ^ijss. 

Tinct. ehiratee ^jss. — M. 

S. — One teaspoonful to be taken three times a day in a little sherry before 
meals. 

Chlorate of potassium is a drug of much use for its local action upon 
the mucous membrane of the mouth and throat, and when ptyalism 
occurs it may be resorted to at once as a mouth-wash and gargle 
(1 : 40). It has no action in the blood upon the disease, as some have 
thought. The following lotion may be used : 

R • — Potassii chlbratis . 3 iv. 

Glycerini boracis (1:5) 5jj. 

Aquse rosse ^ xv. — M. 

S. — To be used as a gargle frequently, and one tablespoonful to be swallowed 
after meals, three times a day. 

In single subjects contemplating marriage the administration of the 
drug in small doses should be continued up until after the event has 
been consummated when this occurs inside two years. Marriage 



818 SYPHILIS. 

should always be put off for at least two years from the period of 
contracting the disease. Where this law cannot be carried out the 
writer makes it a rule to insist upon the absolute necessity for a mild 
mercurial course being followed by the female as soon as conception 
has been known to occur. He considers this latter point a matter of 
the gravest importance, and with a little tact it can nearly always be 
managed without the risk of exciting suspicions which might lead to 
serious unhappiness. 

So much for the treatment of the secondary and intermediate stages. 
The tertiary manifestations of the disease will require another drug for 
their destruction. Iodide of potassium has not yet been mentioned. 
Seldom is it indicated in the secondary period, but occasionally it has 
been found necessary to give it where the early periostitis of bones 
cause much pain, and where the ulceration of the throat does not 
readily yield to mercury. Nevertheless, it is regarded as a drug to be 
reserved for the treatment of the later or tertiary stage. 

The small but continuous doses of mercury, if administered for a 
long time, very materially diminish the chance of tertiary symptoms. 
This view is at least held by several, and it is accepted by the writer. 
It has its influence upon the treatment of the sequelae in this way — 
that, given marked tertiary symptoms in a patient who has had little 
mercury administered to him in his secondary period, this drug will 
be found to act very rapidly in removing them. 

Iodide of potassium is given for every tertiary symptom. Under its 
use large gummatous tumors melt away, and nodes, which had with- 
stood all other agents, disappear as if by magic. Many affirm that its 
effects are transitory, and that relapses always occur, and that in no 
sense is it curative. This is quite true, if its use be not continued long 
after the apparent removal of the local affection ; but there is sufficient 
clinical evidence to show that in many cases, without the use of any 
other remedy, the iodide has effected a removal which had become 
permanent. In dealing with tertiary manifestations, and the effect 
of iodides upon them, one can be quite satisfied that when they dis- 
appear it is not spontaneously, but by the result of the action of the 
drug, as these affections, if let alone, show no tendency whatever to 
resolve. 

Notwithstanding these considerations, it will be a safe rule for the 
physician to make for his own practice, that in no case should the 
action of the iodide be depended upon unless followed immediately 
before or after, or used in conjunction with, mercury in some form or 
other. 

For the group of symptoms known as " intermediate," the best treat- 
ment will be a combination of the iodide with the usual mercurial 
dose. Under this plan choroiditis, testicular sarcocele, and various early 
cerebral affections disappear, and the specific action of the iodide seems 
to increase as the affections become more and more separated from the 
primary stages, as pointed out by Hutchinson. 



SYPHILIS. 819 

Given a case of real and unmistakable tertiary nature, the question 
will arise, should the iodide be commenced at once without waiting for 
the action of mercury? This will depend upon various points in the 
history of the treatment of the case, and also upon the exact locality 
and gravity of the lesion. Where mercurial treatment had not been 
patiently carried out in the secondary stage, the best results are to be 
expected from it. It is in these cases that the Aix method, or the 
vaseline oil and yellow oxide of mercury injections, do so well, even 
after the failure of the drug by the mouth. 

If, then, the tertiary lesion resists mercury, or if it appears, say, in 
the form of a cerebral tumor, the iodide should be commenced at 
once. As a rule, it is useless to begin with small doses. The writer 
has never observed that the best effects may be noticed from small 
doses. Hutchinson states that he has known patients cured in the 
most definite manner by doses of less than a single grain, and he also 
remarks that the most severe untoward effects have followed very small 
doses. 

The writer's plan is to begin with 5 grains three times a day, and 
gradually increase until 20 grains are taken in each dose. It is a very 
remarkable fact, about which there cannot be a shadow of doubt, that 
the irritation and troubles following small doses, say 2 grains of the 
iodide, speedily disappear upon doubling or trebling the dose. Idio- 
syncrasy is not affected in this manner. 

It is not an uncommon experience to find a patient who has taken 
fair doses of the iodide for many months for nodes without the least 
result. If the dose be suddenly increased, say to 20 or 30 grains, the 
nodes begin to disappear as if by magic. 

The American system of giving j ounce doses is not to be recom- 
mended. One drachm in the day meets the requirements of the great 
majority of cases, and, as just mentioned, it is remarkable how soon 
all coryza and other unpleasant symptoms disappear when full doses 
are given. Wood lays down the law that where such doses as these 
are tolerated, it amounts to a proof that the disease under treatment is 
syphilitic, so satisfied is he of the great toleration of the drug which 
this disease establishes. 

One very important therapeutic law may be formulated about which 
there can be little question — i. e., that in tertiary syphilis the local 
action of mercury and iodides is incomparably greater than in the 
secondary lesions, and just in proportion to the remoteness of the ter- 
tiary affection from the secondary, so does the importance of local 
treatment increase. This is demonstrated in cases of rupia, serpiginous 
ulcerations, lupoid growths, and ozsena, where iodoform or mercurial 
applications act like magic after failure of internal treatment with both 
iodides and mercury. 

The choice of local applications will lie, in the majority of cases, 
between the acid nitrate of mercury solution and iodoform applied 
in powder freely or as a strong ointment. The internal administration 



820 SYPHILIS. 

of iodides or mercury must be persevered with at the same time, but 
oftener mercury is found to disagree with tertiary patients than with 
those suffering from the primary or secondary stages of the disease. It 
is in such cases that the calomel bath, injectious, or inunction do so 
well when the drug by the mouth appears to fail. 

Various forms for administering mercury and iodine together in ter- 
tiary syphilis are used. The biniodide of mercury in the form of pills, 
each containing -^ to y-g- grain, is very effective. 

Donovan's solution has long maintained its reputation, and the 
U. S. P. formula (containing 1 in 100) may be given for long periods 
in doses of 20 minims. Perhaps the best of all combinations is cor- 
rosive sublimate, prescribed in iodide of potassium solution. Its great 
advantage lies in the facility with which the iodide or the mercury 
can be increased or diminished at pleasure, according to the effects 
required : 

$ . — Hydrarg. chlor. corros . . . gr. jss. 

Potassii iodidi giij. 

Aquae dest H x ij- — M. 

S. — Half an ounce in a little water, to be taken three times a day. 

This mixture may be given for a month at a time, when the mercury 
may be stopped, the iodide being administered without it. At the end 
of the second month the mercury can be added, and so on each alter- 
nate month. Tannate of mercury is recommended in tertiary syphilis 
in doses of 1 grain twice or three times a day, but it has no advantages 
over other preparations. 

Where large doses of the iodide are to be continued for long periods, 
the iodide of sodium should be selected, as it has a less depressing 
effect. Some authorities advise the use of a combination of the iodides 
of sodium, potassium, and ammonium. Quinquaud has recently advo- 
cated the treatment of syphilis by mercury employed in the form of a 
plaster, applied over the spleen every eight days. His plaster is com- 
posed of diachylon plaster, 3000 parts ; sublimed calomel, 1000 parts ; 
and castor oil, 300 parts, spread upon leather four inches square. If 
salivation be desired, the size of the plaster is to be doubled. 

Szadek has been employing iodol in tertiary syphilis with success, 
and its use may be a distinct gain in a certain class of cases, where a 
slower and more continuous effect is required than that of the iodide of 
sodium or potassium. Its action is identical with these salts, but it is 
more slowly eliminated. He gives it in 15 grain doses in powder 
enclosed in unleavened bread. It may be applied locally, and, though 
less efficacious than iodoform, it is devoid of its disgusting odor. 

When very large doses of the iodides are considered necessary, it is 
well to stop the administration of mercurials for a time, and it appears 
probable that a small proportion of arsenic diminishes the tendency to 
skin eruptions. 



SYPHILIS. 



821 



The following combination may be used : 

R. — Sodii iod. 
Potassii iod. 
Ammonii iod. . 
Liq. potass, arseuit 
Tinct. aurantii amar 
Glycerin, purif. 
Infusi calumbae 









ad 



3iv. 

% xx. — M. 



S. — One tablespoonful to be taken three times a day, after meals, in water. 

The iodide treatment may require, in some cases, a longer period 
than the original mercurial course. Some patients may be kept upon 
it, with occasional breaks, for two years. It must be persisted in until 
every trace of the local affection has long disappeared. It is hardly 
necessary to emphasize the necessity for close attention to the state of 
the general health in tertiary syphilis. Change of air to the seaside 
and a long sea voyage may be necessary in tedious cases. 

Congenital syphilis must be treated upon the same general principles 
as in the ordinary acquired variety. Success is likely to crown the 
efforts of the physician in the most unpromising cases. Failure is too 
often caused by timidity in pushing mercury. It must be borne in mind 
that children bear large doses of the drug safely, and the writer else- 
where {Pharmacy, Materia Medica, and Therapeutics, fifth edition) has 
pointed out that it is almost impossible to do harm with hydrarg. cum 
creta to infants poisoned by syphilis, as long as their tissues are sat- 
urated with the syphilitic virus, as this latter acts as a vital antidote to 
the mercury. When the disease is destroyed by the drug, the child 
begins to show signs of not tolerating it so well. Salivation is almost 
impossible, and it may be laid down as a safe rule that it may be 
pushed as long as the child continues to thrive. 

For an infant six months old i to f grain of hydrarg. cum creta 
may be given three times a day for several days. Then the same dose 
once a day may be continued for many weeks. If the physician have 
doubts about pushing it further, he should make careful weighings of 
the patient, and any steady diminution of weight will be a strong 
indication that the treatment should be suspended. 

The writer is satisfied of the truth of the following statement that he 
made some years ago : " Weak, emaciated infants bear larger doses 
when poisoned with syphilis than they can when afterward apparently 
cured and fattened ; but if, after a period of neglect, syphilitic symp- 
toms come on markedly, then they bear very large doses again." 

The old-fashioned method of smearing weak mercurial ointment 
upon a flannel roller wound round the abdomen is a very good one. 
The movements of the body rub in the drug as in the ordinary opera- 
tion of inunction, but the physician has no guide to the amount 
absorbed. The writer has had excellent results by using a roller satu- 



822 TAPEWOKM. 

rated with cod-liver oil, to which a small quantity of the ointment had 
been added. Over this a broad binder of makintosh is applied, and 
the oil renewed every morning or evening without changing the roller. 
Marked increase of weight always follows this simple but invaluable 
plan. 

The mercurial may be suspended from time to time, but should not 
be discontinued for at least one year. 

Cod-liver oil and syrup of iodide of iron, to which a small quantity 
of iodide of potassium has been added, should be given at various 
opportunities during the course. 

The milk of the child's mother may be given to it with advantage 
if she be also put upon a mild mercurial course at the same time, and 
in very mild cases this treatment may possibly be sufficient. It is, of 
course, out of the question to put the child to the breasts of a healthy 
wet-nurse owing to the danger of infecting her through the nipples. 
If hand-feeding must be adopted, unusual care will have to be taken 
during the first six or nine months, and beef juice should be given at 
least once a day. The milk of the ass is said to do well in such cases. 

TABES DORSALIS— See under Locomotor Ataxia, page 456. 

TABES MESENTERIOA— See under Mesenteric Glands, page 507, 
and under Scrofula, page 773. 

TALIPES— See under Club-foot, page 129. 

TAPEWORM. 

A very large number of drugs are known to act as poisons to this 
parasite when administered in the ordinary way to the patient in whose 
intestines it has taken up its abode. Every year brings out new agents 
for this purpose, but in spite of the great activity in this department 
of therapeutics, the oleoresin of aspidium still maintains its supremacy 
as being the most reliable of all vermifuges. By care in its adminis- 
tration, and by a knowledge of the way in which it acts, the physician 
will very seldom have to resort to any other agent. Its only draw- 
backs are its very nauseous taste and its liability to upset the stomach, 
but these objections can be overcome by improved pharmacy. 

It is efficacious against the taenia solium and bothriocephalus, but it 
must be given in larger doses than those usually prescribed. The dose 
of 15 to 30 minims is useless. Less than one drachm is generally of no 
value. Some authorities recommend a dose of 4 drachms, and J. O. de 
Man publishes a list of twenty-eight cases recently where the dose was 
from 2 to 9 drachms, the average dose being about 6 drachms. 

This dose would probably be generally fatal if the oleoresin was of 
good quality. The male fern is of varying activity, according to the 
soil and climate in which it has been grown, and the only way to recon- 
cile the doses of Man is to assume that he had an inferior extract. 



TAPEWORM. 823 

Potain has pointed out that certain parts of Normandy, for example, 
produce male fern which has no effect. The writer thinks that the vari- 
ous discrepancies regarding the dosage may also to a large extent be ex- 
plained by the difficulty in distinguishing the fronds and rhizomes of 
aspidium jilixmas, asplenium filix-fcerrtina, and others; the filix-mas 
exhibits eight fibro- vascular bundles on a transverse section of the 
petiole-base. The identity of the fern should be carefully made out 
before the oleoresin is prepared, and the physician should be very par- 
ticular about the pharmacist to whom the dispensing of this drug is 
entrusted. Of an active oleoresin four drachms has several times caused 
death. One drachm is, however, a fair average safe dose. 

Several precautions are necessary in order to make the attack upon 
a tapeworm a success, and these maintain in the case of all other ver- 
mifuges or vermicides. Thus, the alimentary canal must be as empty 
as possible, so as to permit the drug to exercise its undiluted effect 
upon the parasite. For this reason these drugs should be given after 
a long fast, or better still, after a brisk saline cathartic. Then, as 
many of these agents simply act by killing the worm, a purgative 
should be given soon after or along with the vermicide. The worm 
must be very closely examined to ensure its complete expulsion. Very 
often only a large number of "joints" are passed, and the head is left 
behind. Failure, then, of course results, as the head goes on growing, 
and the dose should be repeated in such a case after a day or two of 
rest. 

There may be more than one worm — an event much more frequent 
than is usually supposed, and only a very close scrutiny of the detached 
portions will enable the physician to be sure of this. The writer has 
seen this condition of matters twice. 

Given, then, a case of taenia solium, the physician should give about 
4 or 6 drachms of sulphate of magnesia in a bottle of lemonade late at 
night, or very early in the morning by daybreak. A few hours after 
purgation a dose of not less than 1 drachm (in strong subjects 90 
minims) of the oleoresin of male fern is to be administered. This 
should be followed in a couple of hours by a full dose, 6 to 8 drachms 
of castor oil, alone or combined with half a drachm of the spirit of tur- 
pentine. The worm is speedily expelled dead, and the patient should 
be warned to gently wash it and look out for its head. 

There is, as already mentioned, much difficulty in administering the 
drug. The following is a good working formula : 

R . — Oleoresinee aspidii g j 

Ovi vitellum. 

Aquse menth. pip. et syr. simp. . . q. s. ad ^ij. — M. 
S. — To be taken in the morning. 

Many advise turpentine to be added to this draught, and some put 
in 5 grains of calomel, while others insist upon combining small quan- 



824 TAPEWORM. 

tities of every vermicide with which they are acquainted. This latter 
practice is to be condemned, and so is the calomel, which is too slow in 
its action, but the turpentine seems to do good. 

Ether and chloroform are sometimes combined with the male fern 
with the view of increasing its effect and preventing griping. The sim- 
pler the form in which the drug is administered the better. 

Now and then a patient presents himself who cannot possibly keep 
down a draught such as the above. The best thing to do in such a 
case is to get a known and reliable chemist to send a good sample of 
the oleoresin to a capsule maker, and have it freshly made into capsules 
containing 10 or 15 minims in each. Six or four of these quietly swal- 
lowed during fasting may glide through the stomach, and as they rap- 
idly dissolve in the intestine they exercise their lethal action upon the 
parasite. 

It is not a bad plan to give a small dose of laudanum, brandy, anti- 
pyrine, or other sedative, such as peppermint, along with the subsequent 
draught of castor oil, to prevent griping and irregular contractions of 
the bowel, which might tend to break off the worm at the neck. 
There may be no grounds for such a belief, but such a plan can do no 
harm. 

Duchesne advises the following made into a firm jelly, which can be 
easily taken by children : 

R. — Oleoresinae aspidii 2>j- 

Hydrarg. chlor. mit gr. vj. 

Sacch. alb . . . gij. 

Gelatin. . . . . . . - . . . q. s. 

This quantity would certainly be too much for a very young child. 
A boy five or six years old might take the half of it. 

Rothe recommends that chloral hydrate (believed to be a vermicide 
by some) should be combined with the male fern'in combination with 
a smart cathartic in the form of a capsule, the whole given together, 
thus avoiding subsequent pain and the administration of a purgative. 
His formula is : Chloral, 18 grains ; oleoresin of male fern, 30 grains ; 
croton oil, 1 or 2 drops. This is a severe dose, though he says it pre- 
vents pain and griping, and acts inside of three hours. 

Whatever the form in which male fern is given it should only be 
prescribed in two doses at the most, one to be taken the morning fol- 
lowing, or, perhaps, within four or six hours after the first dose. The 
plan of ordering several doses in a mixture to be taken continuously 
after short intervals is apt to lead to severe intestinal inflammation, 
and may cause death. 

The following brief summary of our chief anthelmintic agents may 
be useful for reference when male fern fails : 

Turpentine has long enjoyed the reputation of being a valuable agent 
in killing tape-worm, but to be of any use it must be given in doses 



TAPEWORM. 825 

of at least 4 fluidrachms. This quantity often excites strangury and 
serious symptoms. Moreover, it is most objectionable as to taste and 
smell, and now it is seldom employed for these reasons. If selected 
after the failure of male fern, it should always be given with about 1 
fluidounce of castor oil after fasting. The parasite is expelled dead ; 
and it also affects the round worm. 

Kousso should be given in doses of 4 drachms infused in boiling 
water, which is swallowed without straining as soon as the infusion is 
cold. This dose generally not only kills the worm, but causes its ex- 
pulsion in fragments without any further purgative. Merck has isolated 
the active principle, koussin, which may be given in capsules in doses 
of about 40 grains. Bedall's koussin may also be given in the same 
form, and in similar doses. Wafer paper answers all requirements, and 
the preparations are more certain than the crude drug, which is much 
valued in Abyssinia. 

Kamala acts in the same manner as kousso ; 2 drachms kill and gene- 
rally expel the worm when given (after a long fast) suspended in syrup, 
mucilage, or gruel. Anderson's tincture is made by macerating 9 ounces 
of kamala in 21 ounces strong alcohol, the dose of which is a large tea- 
spoonful. Large doses may purge very severely. 

Pomegranate (the bark or rind of the root) is one of the most certain 
vermicides we possess. Many prefer it to the male fern. It may be 
administered in the ordinary decoction (2 ounces to 20 ounces). Of 
this 5 ounces may be swallowed every hour for three doses after 
fasting. 

A great advance has been made in the therapeutics of this class of 
remedies by the isolation of the active principle of the pomegranate by 
Tanret, who extracted a liquid alkaloid, which he calls pelletierine. 
The tannate of this alkaloid is the best form for administration. It 
may be given in 2 grain doses. 

It is said to be safe in doses of 1 grain for children. Its efficacy is 
said to be increased markedly by a 10 grain dose of tannin given im- 
mediately before it. 

Schroder has demonstrated that the one ten- thousandth part of this 
substance, when added to the fluid in which a living tapeworm is 
placed outside the body, causes its death in a few minutes. 

It should be given fasting. As we learn more about the preparation 
and action of this remedy, it is likely that it may entirely replace the 
male fern. At present, though the reports are glowing, there is some 
confusion about the dose, and profound muscular weakness has resulted 
from 5 or 6 grains, though some authorities, among whom is Boas, 
advise four times this amount. 

Most of the discrepancies regarding the dose of the root bark are to 
be explained by the rapid deterioration of the specimens on being kept 
for any time, 

Pepo — the seeds of the common yellow pumpkin — are found to be 
harmless and often efficient, and, unon the whole, in the present state 



826 TENESMUS. 

of our knowledge, they are the best agent for children. A large tea- 
spoonful of them may be pounded into an electuary, with sugar, and 
given to a fasting child, a purge following in three or four hours. Wood 
gives the adult dose as 2 ounces. The greenish resin obtained from the 
perisperm may be given in 10 to 20 grain doses. 

Embelia ribes seeds, given in similar dose and form as in the case of 
the latter drug, is a favorite East Indian remedy. 

Areca nuts are just at present highly vaunted. They have been 
long prized in veterinary practice. One to 6 drachms have been fre- 
quently given. The proper dose is, perhaps, about 2 drachms, given 
in milk after a long fast, and followed by a very brisk purge. The 
active principle is a liquid alkaloid resembling pelletierine, to which 
the name of arecaline has been given. It has an action resembling 
muscarin. 

Cocoanut has certainly some action, but the milk and the albumin 
of an entire nut must be taken to produce any effect. It may be given 
safely to children. 

Ether and chloroform, and, more recently, the hydrate of chloral, 
have been used with considerable success in full doses, with the view 
of poisoning the worm, which is then to be expelled by a very strong 
drastic. The writer, if compelled to use the first two drugs, would 
combine them with a large dose of castor oil, and in the same way the 
chloral might be given with 1 to 2 drops of croton oil. Rothe gives 
chloral and male fern together in the capsular form, as previously 
mentioned. 

Thymol in large doses has been recently recommended. Gampi has 
given 2 drachms, followed by 5 drachms of olive oil. This dose might 
easily prove fatal. The writer has observed great irritation follow a 
large Warm-water enema containing only a few grains of this sub- 
stance. 

Myrtol, in doses of 2 grains in capsules, has been recommended. 

Menthol would, no doubt, also act like thymol. 

Naphthalin, the intestinal disinfectant, has been tried successfully 
for tapeworm. Five grains may be given in wafer paper. 

Balsam of copaiba (4 drachms), salicylic acid (45 grains), have been 
tried successfully in a few cases. 

No mention need be made of the old mechanical remedies intended 
to dislodge the worm from its moorings by irritating it, as powdered 
tin, iron filings, zinc, charcoal, mucuna, etc. Many, if not all, of the 
strong drastics occasionally act as vermifuges by wrenching the para- 
site from its position in the bowel. 

TEETHING— See Dentition, page 173. 

TENESMUS. 

The treatment of this symptom will depend upon the cause, the re- 
moval of which must be carried out before relief can be obtained. 



TETANUS. 827 

Until the remedying of the cause is effected, some ease may be obtained 
by local anodynes, as morphine suppositories, small enemata of laud- 
anum (40 minims in 2 ounces starch- water), enemata of ice water, or 
injections of large quantities of very warm water. The writer's un- 
guentum conii, now official, is very valuable in some cases. 
(See under Proctitis, Haemorrhoids, Anus, Fissure of, etc.) 
Tenesmus of the bladder will be relieved by the agents mentioned 
under Bladder Affections, Stone in the Bladder, etc. 

TESTICLE, Diseases of— See under Hematocele, Varicocele, 
Hydrocele, Cancer, Scrofula, etc. 

TESTICLE, Inflammation of— See Orchitis, page 557. 

TETANUS. 

Owing to the great diversity that exists in the severity of the cases, 
the exact value of drugs in this disease is open to serious differences 
of opinion. There are some pessimists who believe that the cases 
which recover would have got well without drugs at all. Anyone who 
studies the clinical aspects of the disease cannot fail to observe how 
near to a fatal issue are some of the cases which recover, and how near 
to recovery seem some of those chronic examples of the disease which 
end fatally. It F is obvious that a very little may turn the scale in 
either way, and the value of good nursing and certain drugs should 
be regarded as beyond a doubt. 

The patient should be put to bed upon a good mattress, in a dark, 
quiet room, to which only the physician, nurses, and one or two of his 
most intimate friends are allowed access. Cotton wool is placed in his 
ears to keep out sounds, a thick carpet being spread upon the floor. 

Renzi insists that the physician should grope his way about the room 
with a dark-lantern. The importance of absolute stillness is doubtless 
very great, and the patient should only be permitted to speak when 
absolute necessity dictates. By these precautions, the authority just 
mentioned claims to have cured three out of four cases. 

Feeding is of much importance. Liquid nutritious foods are to be 
poured into the mouth. Stimulants are indicated in full doses in the 
majority of cases, and where swallowing is impossible or very difficult, 
rectal feeding by strong, peptonized broths may be resorted to. As 
this often proves unsatisfactory, Rose's method of giving chloroform 
twice a day may be resorted to, and when complete anaesthesia has been 
obtained, the stomach may be filled through a rubber tube with nutri- 
tious liquid food. 

Constipation may be left alone, as purgatives do a great deal more 
harm than good, and cold or warm baths are to be condemned owing 
to the difficulty in administering them. 

Any wound or injury is to be carefully examined or explored, and, 
by the removal of any foreign body or retained secretiou, all sources 



828 TETANUS. 

of peripheral irritation are to be avoided. Soothing or anodyne 
dressings are necessary, and rigid antiseptic precautions should be 
maintained. 

Some authorities make linear incisions into the neighborhood of the 
wound, and then apply caustics. This is to be condemned. Nerve 
stretching and nerve section, nerve freezing and even amputation have 
been tried, and in a few isolated cases have received the credit of the 
recovery, but such measures cannot be seriously considered except 
under very rare circumstances. Ice-bags to the spine have not given 
any marked benefits to warrant their routine employment ; and the 
same may be said of electricity, which, indeed, may do great harm. 

Of drugs there is practically no end, every known sedative having 
been at some time or other tried, and supposed to have turned the tide 
against the microbe. It is certain that we are unaware of any agent 
possessing a specific or curative effect in severe cases ; but, as already 
mentioned, several drugs may be used to keep the patient alive until 
the disease exhausts itself by elimination, and in the very worst cases 
relief of suffering may be obtained. 

Bromide of potassium in full doses generally somewhat diminishes 
the spasms, and a few mild chronic cases have been reported as cured 
under its influence, but it need not be relied upon where the symptoms 
are severe, unless it be given in combination with the next drug. 

Chloral hydrate has been used in many cases which have recovered, 
and there are good grounds for believing that, it may occasionally save 
life. It must be pushed until the full physiological effects are observed, 
30 grain doses being given every three hours, or 15 grains every hour 
or every second hour until some impression is made upon the symp- 
toms. 

The following mixture may be tried in a severe case in the adult : 

$.- 



Chloral .... 


. • • 3ij- 


Potass, brom. 


• • • 5J- 


Tinct. opii .... 


. 3iv. 


Spt. chloroformi . 


■ • • 3ij- 


Aquse camph. 


. ad gviij.— M. 



S. — One ounce to be given with an equal quantity of brandy every hour. 

In prescribing narcotics in this disease, it must be borne in mind 
that enormous doses may be given. 

Opium by mouth, or morphine hypodermically, may be pushed with 
less danger than chloral, whose depressing influence upon the heart 
may make itself felt before drowsiness appears. These drugs should 
be given in proportion to the spasm and pain, no attention being paid 
to the amount of the dose ; 4 to 6 or even 8 drachms of solid opium 
have been tolerated in twenty-four hours without injury. Some physi- 
cians combine chloral and opium. Cannabis indica may be pushed 
like opium — it is often given with chloral. 



TETANUS. 829 

Alcohol in very large doses, tobacco in nauseating doses, nicotine, 
and tartar emetic may be pushed until sickness comes on. Apomor- 
phine, lobelia, and other depressants have been tried, and in a limited 
number of cases appear to have done some good. Of the series, alcohol 
is the safest — most of them are dangerous. It will be obvious in 
selecting a remedy in this disease that it is better to use one which can 
be pushed until unmistakable physiological symptoms appear and give 
warning when to stop. Nicotine possesses the advantage of being 
easily given by hypodermic injection. 

Chloroform or ether affords the only relief in very acute cases com- 
ing on soon after the wound has been inflicted. In this group of cases 
anaesthesia may be kept up for many hours at a time, and it may be 
pushed even when death is evidently approaching, as the only possible 
way of relieving suffering. 

Calabar bean has been frequently tried, and it certainly has appeared 
to do some good. At one time it was believed that a specific for tetanus 
had been discovered in this drug, but it has failed so frequently that its 
reputation is upon a par with the previously mentioned agents. One 
grain of the extract has been given every half-hour for eight or ten 
doses in bad cases. It generally has little effect upon the spasms until 
dangerous collapse appears, with a fall in the temperature. 

Curare, after a fair trial, has likewise lost ground, and though now 
and then cases are reported which seem to show that it has done good, 
just as often are these set aside by complete failures. One-fourth grain of 
the drug may be injected in 10 minims of water every hour for several 
doses, then every two hours. It is not a drug to be relied upon. 

Pilocarpine, in J grain doses hypodermically, has certainly given 
good results in a few cases, and may be tried when other agents have 
failed. 

Antipyrine and antifebrin have already received the credit of a few 
successes, and cocaine has been recommended upon the result of its 
action in a few doubtful cases. 

Atropine injected into the muscles, or belladonna and hyoscyamus, 
gelsemium and conium by the mouth, in doses sufficient to produce 
toxic symptoms, have been recommended. 

Nitrite of amyl and nitro- glycerin occasionaly appear to give some 
relief, according to several reports. 

Quinine in large doses (1 drachm to 2 drachms) has been several 
times reported as successful. 

Strychnine has been given in chronic cases. Its utility is very 
doubtful. It might, however, be combined with chloral to minimize 
the dangerous depressing influence of that drug upon the heart. 

Now that the microbic origin of the disease may be regarded as 
settled, we may from henceforth expect torrents of suggestions for the 
administration of every conceivable antiparasitic agent. Already 
salicylates and bichloride of mercury are being tried. 

It will thus be observed that, as far as drugs are concerned, the 



830 TETANY — THREAD-WORM. 

treatment of this formidable malady cannot be said to be in a satis- 
factory state. Given a very virulent case, the best relief will be ob- 
tained by narcotizing the patient with chloroform ; and in ordinary 
examples of the disease, in the writer's opinion, the best line to proceed 
upon is absolute rest, the strictest quietness, almost total darkness, full 
doses (1 to 2 ounces) of whiskey, and for medical aids chloral and 
bromides, which should be pushed to the extent of giving eight or ten 
hours' sleep. The great danger in the use of our therapeutic agents 
lies in the temptation of flying from one drug to another, instead of 
pushing some particular one. 

Tetanus or trismus neonatorum may be regarded as the same affec- 
tion as tetanus in the adult, and must be met by the same remedies. 
Chloral is the only drug to be depended upon, and the writer has 
satisfied himself about the great value of it when steadily pushed in 
the case of infants. One grain may be given by the mouth or by the 
bowel every hour. The utmost cleanliness in the dressing of the 
stump of the umbilical cord must be attended to, as this affection is 
liable to spread among newborn infants. 

Soltman recommends -§■ grain of ■ musk every three hours when 
hourly doses of chloral for twenty-four times have failed. Morphine, 
calabar bean, curare, and the other potent agents should not be 
thought of. 

TETANY. 

The treatment of this rare condition is in the same unsatisfactory 
state as its pathology. In the present state of our knowledge or igno- 
rance, the best agent appears to be the bromides in full doses. Few 
authorities now endorse Trousseau's heroic plan of bleeding and cup- 
ping. The local application of chloroform alone or with aconite or 
liniment of belladonna is worth trying. 

Hyoscyamus or hyoscine hypodermically may be tried. 

Chloral, except so insure sleep, should not be employed, owing to 
the chronic nature of the ailment in some cases. 

The general health of the patient should be seen to, and quinine, 
iron, cod-liver oil, and arsenic may effect results after all the antispas- 
modic agents mentioned under tetanus have failed. 

THORACIC ANEURISM— See under Aneurism, page 41. 

THREAD-WORM. 

The destruction of these parasites is often a most difficult and tedious 
process, especially in the adult. There are still several points in their 
life history which require clearing up before we can be very certain 
of the best way to get rid of them. It is, however, certain that their 
ova, getting about the finger-nails, may find an entrance into the body 
again. Absolute cleanliness is, therefore, an essential. It is also highly 
probable that as they wander about the anus and vagina they may be 



831 

communicated from one person to another sleeping in the same bed. 
Their origin in the human subject arises from eating uncooked vegeta- 
bles and fruits, and from drinking water containing their ova. They 
chiefly infest the lower end of the great intestine, but Cobbold insists 
that their presence here is accidental, their real locality being as high 
up as the caecum. 

All these points are of great importance as regards their treatment, 
especially their " locality," but in this later point many authorities do 
not agree with Cobbold. It is still believed to be possible to reach the 
worm and cause its destruction by enamata, which, of course, could 
hardly be possible if the caecum was to be reached in every case. 

The symptoms caused by the presence of these pests can generally 
be speedily relieved by enemata containing a large spoonful of chloride 
of sodium in a tumblerful of water. Lime-water, infusion of quassia, 
solutions of alum, of aloes, of ether (in water), of eucalyptus oil, of 
tincture of iron, of weak carbolic acid, of turpentine, of vinegar, of 
tansy, of olive oil, of chloride of ammonium, and many other sub- 
stances are very useful, and, in the case of children, are generally suc- 
cessful after a few repetitions of the enema. 

A little mercurial ointment just placed within the sphincter keeps 
them from migrating at night. 

Cobbold attaches most importance to internal remedies, and he 
advises iron in tonic doses, with aloes and asafoetida occasionally, fol- 
lowed by repeated saline cathartics, as the Friedrichshall and Hunyadi 
waters. Others recommend large draughts of quassia or gentian in 
infusion, swallowed fasting, and followed by a saline. 

Santonin has been given with success. 

The writer has always succeeded with salt and water enemata, and 
in troublesome cases with the internal administration of a course of 
iron and arsenic, giving an occasional purge of scammony and calomel. 

THROAT, SORB. 

The treatment of this affection, which is known under various names, 
as sore-throat, ulcerated sore-throat, hospital sore-throat, follicular 
tonsillitis, etc., is simple. The constitutional symptoms, which may be 
very severe in some cases, demand attention even before local treat- 
ment. Of the various drugs none act so satisfactorily as antipyrine. 
The backache and headache and high temperature speedily subside 
under a few 10 grain doses of this drug. Salol in drachm doses and 
salicylate of sodium give relief also, but the writer finds nothing so good 
as the antipyrine, and he has had the personal experience of many 
attacks. Where this drug cannot be tolerated (which is seldom), the 
plan of small doses (J minim) of tincture of aconite every fifteen or 
thirty minutes for eight or ten times is very valuable. Veratrum 
viride acts in the same way. These drugs may be combined with 
mindererus spirit and nitrous ether. Quinine in full doses, 10 grains 
immediately, and 5 grains every hour for two or three times, an emetic 



832 THROAT, SORE. 

dose of ipecacuanha, cimicifuga, large doses of guaiacum, a full saline 
purge, have all proved efficacious in relieving or cutting short the early 
symptoms. 

A milk diet with strong soups, and, in debilitated subjects, a liberal 
allowance of port, claret, or a weak milk punch may be ordered. 
Abundance of pure air and good ventilation are as essential to the 
patient as they are to those coming in contact with him, for the disease 
is highly infectious, and easily spread through sewer gas and polluted 
water. Locally the best gargle is the following : 

R. — Cocainse hydrochlor gr. viij. 

Glycerini giv. 

Acidi carbolici 3J. 

Aquse rosse ad J;xij. — M. 

This may be used as a spray or gargle alternately when diluted 
with an equal quantity of water. It is the best treatment in children 
when sprayed over the throat every half-hour. 

Insufflations of powdered bicarbonate of sodium every fifteen min- 
utes are said to sometimes abort the disease. 

Cold compresses, warm poultices, or iced cloths to the outside of the 
throat may be employed, the selection of each being made upon the 
report of the sensations of the patient. 

Painting the tonsils and pharynx over with a strong solution of 
nitrate of silver (3J to gx) occasionally cuts short the attack, and is 
reported to give speedy relief. It far more frequently aggravates the 
suffering, and does no manner of good, and, as a routine remedy, should 
not be employed in the early stage of the affection. 

At a later stage it very often does great good. When the dysphagia 
is very severe no remedy gives the relief which may be obtained by a 
good steaming over boiling water, but the various inhalers, when used 
for this purpose, are worthless. A large basin of boiling, or very hot, 
water should be placed in the bed beside the patient's head, and a 
linen sheet thrown loosely over all, so as to make a tent, is the best 
way to utilize the hot vapor. 

At a later stage alterative or astringent gargles may be used, and 
these can also be employed as sprays. 

The following formulae may be tried : 

R . — Potassii chloratis . . . •. . . . ^ ss. 

Aquse dest. . . ^> xx - — M. 

S. — To be used as a gargle or spray every two hours. 

It is a common mistake to persist too long in the use of this drug, 
as it may keep up the irritation. 

R . — Acidi borici 3 j. 

Acidi carbolici 3J- 

Infusi rosse ^ xij. — M. 



833 

The great advantage in carbolic acid lies in its power of paralyzing 
the palatal muscles and preventing the painful and useless attempts at 
swallowing the saliva and mucus, acting also as it does as a local 
anaesthetic. The lozenges may be slowly sucked in the mouth instead 
of using the drug as a spray or gargle. 

Balls of nitre, pieces of guaiacum resin, compressed tablets of chlo- 
rate of potassium and cocaine, crystals of borax, pieces of ice, and 
catechu lozenges are favorite local remedies. 

As the acute symptoms pass off the value of astringents in hastening 
recovery is obvious. The following formula is useful : 

R. — Tinct. ferri chlor ^ij. 

Glycerini gj. 

Aquae dest. . ^ x. — M. 

This is indicated where there is much redness of the entire mucous 
membrane — a condition spoken of as erythematous tonsillitis, or when 
very acute or formidable as phlegmonous tonsillitis. In both these 
conditions the tincture of iron should be given internally in full doses 
(30 to 60 minims) at the same time, and combined with this treatment 
large doses of stimulants are clearly indicated. 

A good astringent gargle may be made by mixing 1 ounce of the 
glycerin of alum (1:6) with 9 ounces rose water; or tannic acid, 1 
drachm in 10 ounces infusion of roses. 

At a later stage the throat may be swabbed out with the two last- 
mentioned drugs dissolved in glycerin. Capsicum is only available in 
the very last stages. 

Where there is fetor, weak solutions of chlorine, permanganate of 
potassium, creolin, iodine, sulphurous acid, chloride of zinc, or very 
dilute bichloride of mercury are indicated. 

As convalescence is approached, tonics with the mineral acids, iron, 
quinine, and bitters may be indicated. 

Acute tonsillitis is to be treated upon exactly the same lines as the 
follicular tonsillitis or sore-throat — many cases of either disease run- 
ning into the other or becoming undistinguishable. 

Antipyrine or salicylates internally, hot poultices externally, with 
steaming over boiling water and sprays of carbolic acid, to which a 
little glycerin of borax and cocaine have been added, are the main 
drugs to be relied upon. 

Abscesses, as they occur in the tonsil, may be evacuated when the 
suffering is great. This may be accomplished by taking a sharp - 
pointed bistoury, and protecting its blade with a layer of strapping 
until within three-eighths or one-half inch of Its point, it may be thrust 
into the prominent part of the tonsil, the cutting edge being directed 
inward, so as to avoid danger to the internal carotid artery. The 
opening of large abscesses may be imperative, as deaths have occurred 
from suffocation caused by their pressure or by the pus being discharged 



834 

into the air passages, especially during sleep or by the supervention of 
oedema of the glottis. Tracheotomy may be demanded, but the indi- 
cations for its performance are very rare indeed. 

Cocaine, 4 or 6 per cent, solution, should be well swabbed over the 
tonsils and pharynx before the knife is used, and the local anaesthesia 
produced by it will enable the surgeon to insert his index-finger against 
the swollen tonsil, while the fingers of the opposite hand are made to 
cause firm pressure against the tonsil from without at the angle of the 
jaw as he feels for fluctuation. As the abscess has been often known 
to burst during the act of vomiting, it has been suggested that an 
emetic should be given with the view of causing its rupture. 

The treatment of enlargement of the tonsils may, for convenience, 
be here referred to, 

The first step in the treatment should be to remedy the constitutional 
condition, of which the chronically inflamed or hypertrophied tonsils 
may be regarded as the local manifestation. 

In the great majority of cases this will be found to be scrofula, and 
the various agents found useful in the treatment of chronically- 
enlarged strumous lymphatic glands may be tried with the view of 
reducing the lymphatic growths in the tonsils. Iodine internally, 
combined with iron and cod-liver oil, and hypophosphites, sea air, 
good food, and the various remedies mentioned under scrofula, upon 
page 773, should be resorted to with some hope of success, even in very 
indolent cases. 

Locally astringents, as the glycerin of tannin (1 : 5), may be painted 
night and morning over the tonsils, but the result is generally disap- 
pointing. Tincture of iodine or chloride of iron may be painted on 
twice a day ; but of all applications the writer has obtained the best 
results from the following applied twice daily by means of a large 
camel's hair pencil : 

R . — Tinct. iodi 5 jss. 

Glyceririi aluminis (1:6) 5jj. — M. 

S. — To be used as directed. 

Where the iodine causes nausea or irritation the plain glycerin of 
alum may be used, or the iodine may be replaced by 4 drachms of the 
glycerin of carbolic acid (1 : 5). Alum in fine powder may be insuf- 
flated, or the recesses of the tonsils may be filled up with it ; but, as a 
rule, this treatment causes so much discomfort and yields so little 
apparent benefit that it is given up very soon. Gargles in every form 
are useless, save in allaying attacks of acute catarrhal inflammation 
upon the top of the old hypertrophy. 

Where constitutional remedies and the local agents fail after a 
reasonable time (say three months) to make an impression upon the 
size of the organs, operative measures are clearly indicated. Puncture, 
after cocaine has been used, may be tried next. The fine point of the 



TIC DOULOUREUX — TINEA. 835 

galvano-cautery at a dull, red heat is to be pushed into the tissue of 
the gland in several places. This treatment is to be practised every 
third day for about a month or six weeks. The results obtained by 
Valat and others are very satisfactory. 

Where failure ensues the tonsil should be removed, or the hyper- 
trophied growth sliced off. This can be readily done by seizing the 
gland on its inner aspect by a forceps or vulsellum, and slicing off a 
sufficient amount by a sharp blunt-pointed bistoury, with the blade 
protected by lint or plaster for about f of an inch from the point, the 
incision being made upward and inward. The " guillotine " is, how- 
ever, nearly always used. By this simple contrivance any depth of 
growth can be removed without danger. The writer had, however, 
experienced difficulty in using it where the tissue of the tonsil was very 
tough and firm, until he learned by applying with his index-finger 
pressure from without to steady the swollen gland before the advancing 
blade of the instrument ; by this plan the worst cases are easily sliced. 

As a rule, the hemorrhage is very slight, and is best stopped by the 
galvano-cautery, or by strong solution of chloride of iron. See also 
under Laryngitis, Pharyngitis, and Hoarseness. 

THROMBOSIS— See Phlebitis, page 632. 

THRUSH— See Stomatitis, page 785. 

THYROID GLAND DISEASES— See Goitre (page 283) and Goitre, 
Exophthalmic (page 287).. 

TIC DOULOUREUX. 

Under Neuralgia, pages 521 to 536, the treatment of this affection is 
fully detailed. In that article it was neuralgia as it affects the tri- 
geminal or trifacial nerve, which was before the mind of the writer. 
Hypodermic injections of morphine to relieve the very acute agonizing 
attacts of pain are indicated at the beginning. The relative values of 
butyl-chloral, gelsemium, chloride of ammonium, quinine, cannabis 
indica, antipyrine, exalgine, blisters, electricity, nerve section, and 
other agents are discussed upon the pages referred to. 

TINEA. 

Under this term is included ringworm, as it affects the different parts 
of the body. Thus, when the parasite — trichophyton tonsurans — 
infests the skin upon which the beard grows, it generally receives the 
name of tinea sycosis, and its treatment is detailed under Sycosis, on 
page 805 ; but it will be observed that there are two varieties of that 
affection, the remedies suitable for each being detailed. One of the 
varieties is not caused by the trichophyton. 

When ringworm affects the body, it is generally spoken of as herpes 
or tinea circinata, and the treatment of this condition may be first 



836 TINEA. 

detailed, as it is much simpler than when the parasite attacks the hairy 
scalp— tinea tonsurans. 

In ringworm of the body, almost any antiparasitic remedy will 
suffice to stamp out the disease in a very short time if in the early stages. 
The writer, in a pasture-land district, had a very large experience of this 
complaint upon his entry into the profession. The disease is communi- 
cated directly by cows, and often assumes a formidable appearance in 
those individuals contracting it directly from the animals. Even in 
severe cases he noticed that the scalp and hairy parts of the face were 
very rarely affected, and a few applications of the ointment of the 
iodide of sulphur (£ drachm to 1 ounce lard) very soon caused its de- 
struction. 

Of the hundreds of agents used against tinea, there is none to be 
compared with this for quickness of action and efficacy. It has, how- 
ever, its drawbacks, especially when rubbed into sensitive skins, as it 
causes eczema and often severe irritation. The thick skin of the 
agricultural laborer, exposed to the varying vicissitudes of an out-door 
life, will bear an ointment of 1 : 8, but the city clerk or school-girl 
may suffer from the application of even quarter this strength. 

As stated under Sycosis, this ointment should be very carefully com- 
pounded, and it is best to have it prepared for some time before being 
used. When these precautions are taken, the above ointment may be 
used for some time without causing much irritation, and it will be 
found exceedingly satisfactory in all forms of the disease. 

Tincture of iodine often suffices after a few applications. 

Ohrysophanic acid ointment is also highly efficacious. 

Oleate of mercury, citrine or white precipitate ointment, carbolic 
acid, iodine ointment, strong acetic acid, creasote, menthol, thymol, 
corrosive sublimate, sulphurous acid, gunpowder made into a paste, 
even writing ink, and, as already stated, almost any of the hosts of 
parasiticides, suffice to destroy trichophyton tonsurans on the smooth 
parts of the skin. The physician must always remember that the 
eczema produced by these agents may remain long after the parasite is 
dead, and it is liable to be kept up for an indefinite period as long as 
the use of the remedy is persisted in. It is thus not a rare occurrence 
for patients to present themselves to a physician who are suffering from 
the abuse of agents long after the necessity for their application has 
passed away. The cessation of the irritating ointment or lotion, and 
the application of a little lard, lanoline, or oil, suffices in a few days to 
demonstrate the nature of the case. 

When the parasite attacks the hairy scalp, the treatment of the dis- 
ease will often weary the patience of both physician and victim. If 
seen to at the very beginning of its progress, prompt treatment will 
generally prove nearly as satisfactory as in ringworm of the body. 

The ungt. sulph. iod. may be tried with every hope of a speedy cure 
if the parasite has not already got a good start in its march toward the 
recesses of the hair follicles. Before applying remedies the hair must 



TINEA. 837 

be carefully clipped as short as possible over and around the diseased 
area. At a later stage shaving and epilation may be necessary. The 
(1 : 16) ointment is then to be rubbed into the spots, the margins 
receiving a fair share of attention, the application being repeated as 
often as possible without causing undue irritation. 

In about ten days the applications may be discontinued, and as the 
irritation caused by the remedy subsides, a fair idea of the success or 
failure of the battle will be obtained by a careful examination of the 
hairs in the affected region. If these show the characteristic stumpy, 
broken, and irregular appearance, it is clear that more radical meas- 
ures are necessary. 

The great majority of cases presenting themselves for treatment for 
the first time will be found in this stage. If many such spots exist, it 
will be advisable to clip or shave the entire scalp, but the irregularly- 
formed hairs or stumps must be removed singly or in limited groups 
by pulling them out with epilation forceps. This process will require 
many repetitions during the tedious treatment of all bad cases, and it 
will be necessary to teach the nurse or relatives of the patient how to 
perform it skilfully. 

After epilation the ungt. sulph. iod. may be rubbed in ; and as the 
object of the physician is now to cause irritation or blistering, so as to 
loosen the remaining stumps and permit the remedy to get into the 
recesses of the tissue, a stronger ointment than the above may be re- 
sorted to. It may be necessary at intervals to cause actual vesication 
by repeated applications of blistering liquid or of the strongest acetic 
acid. Poultices or warm fomentations may be employed for the re- 
moval of the scabs caused by the blister, after which the parasiticide 
may be freely rubbed in. This treatment, coupled with epilation and 
a thorough washing of the scalp once every week or ten days, will in 
time eradicate the disease. 

As long as a single broken or brittle hair-stump remains, the affec- 
tion, if let alone, will burst out again. At this stage it will be neces- 
sary to go over the diseased area with a lens in a good light, and as 
soon as the young, well-formed downy hairs are found to sprout over 
the region, hostilities may be suspended and the patient permitted to 
mix among other healthy children. 

To the student the treatment of this affection is most perplexing, 
chiefly because of the hosts of different agents recommended, every 
specialist urging the superiority of some particular parasiticide ; and 
it must be clearly recognized that it is not to any great degree in the 
choice of the weapon which he selects, but to the skill and, above all, 
to the patience which he exercises in its use that success depends. 
Though the writer begins and ends the treatment of ringworm with 
the iodide of sulphur in most cases, sometimes during the progress of 
the disease this agent must be left aside, and less irritating substances 
substituted. A close study of a few typical cases from day to day will 
soon show him what variations are necessary in the remedies or in the 



838 TINEA. 

manner in which they are to be employed. It is advised sometimes to 
change one remedy after another every week or fortnight until the 
disease yields, and the writer has heard a celebrated specialist recom- 
mend physicians to " ring the changes " until a remedy is lighted upon 
which will destroy the parasite. This is not to be seriously accepted. 
It is only by the constant observance of the action of a few good 
agents, when employed under the ceaseless changes of conditions such 
as take place in chronic tinea tonsurans, that skill in the treatment of 
this affection can be acquired. 

An oleate of mercury ointment may be used from the very begin- 
ning, and it gives excellent results, and in many cases* it is preferable 
to the iodide of sulphur in thin-skinned patients. 

Glycerin of carbolic acid (1 : 4) is also much praised, but this agent 
in the writer's hands has been disappointing. 

Some of the French physicians adhere to the application of a 1 per 
cent, ointment of protochloride of iodine in lanoline, rubbed in after 
spraying the scalp with warm water and thoroughly drying, and they 
affirm that epilation is never needed under this treatment. 

Vidal maintains that the parasite is aerobic, that all that is neces- 
sary is to deprive it of oxygen and it must die, and that this can be 
achieved by covering the part with vaseline. Nevertheless he uses a 
weak iodine ointment (5 grains to 1 ounce), and covers it with gutta- 
percha tissue. He is probably correct in his aerobic theory, but the 
experience of every physician proves that ringworm of the scalp may 
cease to grow, but still may exist for many months or years under a 
layer of greasy ointment or pomade. 

Thin, with more reason, maintains that ringworm of the scalp can 
be certainly cured by agents which do not destroy or even lower the 
vitality of the spores, and this he has ably demonstrated to take place 
under the use of croton oil. He has shown that spores which are 
soaked in the pure oil grow luxuriantly after their removal from it, 
and he has satisfied himself and many others that it is the irritation or 
inflammation produced by ringworm remedies, and not by virtue of 
their parasiticidal properties, that they cure the disease in the scalp. 
Croton oil is, however, liable to cause much irritation, and baldness 
may result from it. 

If the views of Thin be correct, there is no difficulty in seeing how 
the iodide of sulphur acts so efficiently, but even if these views are to 
be accepted as correct, it still stands to reason that such an agent 
should more quickly destroy the disease than a pure irritant. 

Harrison recommends a prophylactic pomade for the heads of all 
children in a house where ringworm has broken out. Its formula is : 
Ointments of eucalyptus and boric acid, of each 2 ounces ; cocoanut 
oil, 2 ounces ; and oil of cloves, J drachm. He strongly recommends 
the following ointment for the established disease: Caustic potash, 
9 grains ; carbolic acid, 24 grains ; lanoline and oil of cocoanut, of 
each 4 drachms, perfumed with cloves or rosemary. 



TINEA. 839 

Hutchinson's plan of treatment is undoubtedly a good one in all 
very chronic cases. He advises the hair to be shaved or cut close, and 
the scalp to be washed well twice a week with a teaspoonful of liquor 
carb. deterg. in a pint of water, and the following ointment to be 
rubbed in once or twice daily according to the effect produced : 

R. 



-Acid, clirysophanic 


3J- 


Hydrarg. amnion 


gr. xx. 


Lanolin, purif. . . 


3J- 


Adip. benzoat. ....... 


3vj. 


Liq. carb. deterg 


m^-M 



He wisely states that " The secret of success consists in the patient 
continuance of the same remedy. I usually promise with great confi- 
dence a cure to the persevering, but never a rapid one. It is only the 
impatient who are disappointed. Those who change every few weeks 
from one remedy to another find ringworm almost incurable." He 
further states that he has never seen chronic ringworm resist careful 
and persistent application of chrysophanic acid. Unna also depends 
upon it. Bertarelli employs pitch plaster for epilation before apply- 
ing the bichloride of mercury. 

Boric acid, salicylic acid, tar, sulphur, and sulphurated potassium 
ointments, have been used by some who consider time no object. They 
will cure if persisted in, and cause very little irritation. The same 
may be same of oil of cade, oil of naphtha, paraffin, ichthyol, and most 
essential oils. Even cod-liver oil has its list of cures when applied 
locally. 

Some authorities reject greasy applications altogether, and adhere 
to watery or spiritous solutions, and these appear* to do well in some 
cases. One of the most drastic applications is that of Quinquaud. He 
applies it daily after shampooing the head : 

R. — Hydrarg. iodidi rub. . . . - . . gr. iij. 

Hydrarg. chloridi corros gr. xv. 

Spt. vini rectif. . . gx. 

Aquae dest % viij — M. 

After applying this he curettes all the diseased spots, and in a week, 
he epilates and applies a plaster of the biniodide of mercury. 

Cavafy's lotion is used in the early stages of superficial and exten- 
sive ringworm of the scalp. Its formula is : 

R . — Acidi borici gj. 

JEther. sulphuric ^j. 

Spt. vini rectif. % v. — M. 

This should be sponged over the affected spots several times a day* 
It is of no use whatever when the disease has already invaded the 
hair-bulbs. 



840 TINEA. 

The tincture of iodine is, perhaps, the best of all the liquid prepara- 
tions. Some physicians even get excellent results from a weaker tinc- 
ture. Very inveterate spots may be touched occasionally with iodized 
phenol (1 ounce iodine and 4 ounces carbolic acid), or with a modifica- 
tion of Coster's paint, consisting of 1 ounce iodine and 1 ounce creasote 
or oil of cade. Strong acetic acid is sometimes used all through the 
treatment when oily or greasy preparations are objected to, and every 
known soluble parasiticide drug may be used in the form of lotion. 

Sulphurous acid is frequently employed, but it does not penetrate to 
a sufficient depth. This is the objection to watery solutions, viz., that 
they do not penetrate into the bottom of the hair follicles. 

When lotions are employed the scalp should be washed daily, and 
the best way to do this is to employ borax instead of soap in the water 
used for washing. 

Shoemaker's method of treating ringworm of the scalp deserves 
special mention. He condemns cutting, shaving, epilation, and blis- 
tering as worse than useless, and begins the treatment of a case by 
sponging the diseased spots over with a weak alcoholic solution of 
thymol, borax, napthol, or mercuric chloride, and then thoroughly 
saturates them with a 50 per cent, solution of boroglyceride, which 
latter remedy he feels cannot be too highly extolled. It is mopped on 
with a brush, and rubbed in with the fingers. If this fails, without 
epilating he proceeds to rub in the ointment of the oleate of copper, 
prepared with either 4 or 9 parts of a fatty base. A little only need 
be applied. In chronic cases he alternates this treatment with applica- 
tions of the oleate of mercury of 5 per cent, strength for children, and 
20 to 30 per cent, for adults. 

He states that he. has never once seen salivation produced by this 
remedy, though he rubs it in twice daily for weeks until the parasite is 
completely extirpated. 

In the form of ringworm of the most chronic and inveterate type 
where the parasite has got down deep into the hair follicles before the 
disease has been noticed, and where it is scattered over the entire scalp 
in very small detached spots here and there, the treatment is most 
tedious and disheartening. A modification of Alder Smith's method 
may be tried in such cases. The scalp is to be searched over with a 
lens, and wherever a stumpy hair or small group of such appears, the 
spot is to be touched with a very fine camel's hair pencil dipped in 
croton oil. This should be done for several days in succession, and if 
free pustulation does not occur, a warm linseed poultice may be 
applied over all. 

This method is very different from the routine application of the oil 
to large tracts of the scalp, a plan, though efficacious in many instances, 
is, as already mentioned, liable to be followed by severe irritation and 
even baldness. The suppuration around and in the minute spots causes 
the broken hairs to be protruded from their sockets, as in the variety 



TINNITUS. 841 

of ringworm known as kerion. As a final touch to the parasite, a 
strong oleate of mercury ointment may be rubbed into each spot. 

In tinea kerion, nature has already almost effected a cure, and the 
inflammation caused by the parasite has led to the falling out of most 
of the hairs. In this case epilation of the remaining loose hairs, and 
the application of a weak bichloride of mercury or a strong lead and 
opium lotion, suffices to speedily perfect the cure. Boroglyceride does 
well in these cases. 

During the entire period of treatment the patient's head should be 
covered by a small silk cap ; and rigid precautions are to be taken, 
especially in the case of schools, where each child should have separate 
sleeping accommodation, with washing and toilet requisites. 

Liveing warns against the use of greasy or sticky prophylactics, and 
insists upon the head being well washed daily with warm water and 
soap, but Hutchinson believes that it is to the decline in the fashion of 
using greasy pomades that the prevalence of ringworm is now due. 

In schools, the writer depends upon a pomade or oil containing 
paraffin, and the immediate application of the ointment of the iodide of 
sulphur to all suspicious spots as they appear. Hutchinson recom- 
mends his own treatment highly in the case of scnools, but the writer 
has had experience of the iodide of sulphur in several outbreaks of 
ringworm in a large charity school, and he believes it cannot be im- 
proved upon. 

Though there is not so much in constitutional treatment as many 
writers claim, nevertheless, successful management of chronic cases 
may not be possible until the general health is improved. This is 
especially true in those cases where troublesome eczema or impetigo 
complicates the disorder. Cod-liver oil, quinine, iron, arsenic, and 
other tonics, in combination with pure sea air and good food, may be 
tried. 

TINEA FAVOSA— See Favus, page 263. 

TINEA SYCOSIS— See Sycosis, page 805. 

TINEA TARSI— See Blepharitis, page 70. 

TINEA VERSICOLOR— See Pityriasis Versicolor, page 661. 

TINNITUS. 

The treatment of this sometimes distressing symptom will depend 
entirely upon the cause. Thus, where wax or any foreign body lies 
against the tympanum, its removal is followed by instant relief. 

In throat affections and in Eustachian obstructions air must be per- 
mitted to enter the tympanic cavity. Inflammation of the middle or 
internal ear may give rise to it. (See Ear Diseases, page 218.) Though 
any local cause sufficient to produce irritation of the acoustic nerve or 

54 



842 TONGUE, DISEASES OF. 

alterations in the local blood pressure, will commonly produce tinnitus, 
it must not be forgotten that it may be reflex — produced by dyspepsia, 
renal, and hepatic diseases, and by the irritation arising from decayed 
teeth, etc. 

Where the symptom arises from incurable local conditions or from 
central nervous affections, some relief may be obtained from a combi- 
nation like the following : 



B • — Acid, hydrobroni. dil. 



3jss- 



Liq. potass, arsenit gij. 

Strychninse . . . . . . . gr. jss. 

Aquse camph ad ^ vj. — M. 

S. — One measured drachm to be taken three times a day in a wineglassful 
of water, after meals. 

Chloride of ammonium alone, or with bromide of ammonium in 
doses of 15 grains each, has often given relief in the writer's hands 
in very chronic cases. Locally, blisters behind the ears or veratrine 
ointment may give relief; sometimes air charged with vapor of chloro- 
form injected into the Eustachian tube for a time dispels the dis- 
comfort. 

TONGUE, Diseases of. 

Under Cancer, upon page 101, the treatment of malignant affection 
of this organ is briefly detailed. 

Removal of the entire organ may be achieved by the use of the 
ecraseur through the mouth, or through an incision in the floor of the 
mouth, so as to apply it as far back as possible. The gal vano cautery 
has also been used ; but both these operations are now.not so frequently 
done, owing to the sloughing of the tissues following them. The ecra- 
seur is, however, still much used in conjunction with the knife and 
scissors, as the hemorrhage is more under control by its use. Thus 
Baker splits the tongue for its entire length through the middle line. 
After cutting all the muscular and mucous attachments of each half 
with scissors, he then draws it well forward by stout threads passed 
through each half and lays the ecraseur on well behind the diseased 
structure. Each half is removed separately. He employs stout whip- 
cord instead of the chain. 

Whitehead excises the entire organ by means of scissors only. 
The tip is well drawn forward from the gagged mouth by a strong 
thread passed through it. After snipping through the frenum and all 
the muscular and mucous attachments, the organ is easily removed 
with but slight hemorrhage, the lingual arteries being tied or twisted 
as they are cut, and a ligature through the base is left in for a 
day. 

Many complicated operations are planned for the removal of the 
organ after dividing the lower jaw. Those of Syme, Langenbeck, 



TONGUE, DISEASES OF. 843 

Sedillot, Billroth, Reguoli, and Kocher are done in this way, but they 
have steadily given way to the safer and more expeditious methods of 
Baker and Whitehead. 

The floor of the mouth should be well packed with iodoform gauze, 
and the powdered drug dusted freely over the stump. 

Food is administered by a rubber oesophageal tube and by the 
rectum, Hemorrhage may be controlled by ice, by the puff-ball, or 
by pressure. 

Inflammation of the tongue is to be treated as described under the 
article Glossitis, upon page 283 . 

Superficial ulcerations are to be dealt with as mentioned under 
Stomatitis, upon page 785, and under Aphthae, page 51. 

Syphilitic affections of the tongue are to be treated by the rules and 
principles mentioned under Syphilis, page 810. Ulcerations may be 
freely touched with the acid nitrate of mercury, or with the solid 
caustic stick. 

Hypertrophy of the tongue or macroglossia has been, when of 
limited extent, successfully treated by pressure in a few cases. Any 
concentrated astringent solution which does not produce irritation 
may be applied on strips of lint wrapped around the enlarged and 
protruding organ. Over these, strips of isinglass plaster may be 
placed so as to exert moderate pressure in a uniform manner. 

In some instances, when the tongue can be retained inside the 
mouth, benefit has been obtained by pushing it back and keeping 
the jaws together by a rubber or other bandage passed over the 
head. 

As a rule, where the enlargement is great, the question of operation 
will have to be met. This may be done by the knife, scissors, ecraseur, 
thermo- or galvano-cautery. A few stout needles are passed through 
the enlarged organ in front of the spot where the section is to occur, 
the tip being well pulled forward, the ecraseur is laid on, and the 
anterior portion of the tongue removed. 

Where the deformity is not so great the favorite operation is to 
make a ^-shaped incision, and remove the wedge of tissue by the knife 
or scissors, after which the edges of the incision may be brought to- 
gether by a series of deep and superficial wire sutures after any bleed- 
ing vessels have been secured and twisted or ligatured with catgut. 
When the surgeon has the choice of time he may defer operation until 
about the end of the fourth month, but where feeding is rendered 
difficult he must operate sooner. 

All authorities who have written upon this peculiar malformation 
recommend cod-liver oil, though it does seem to the writer very 
difficult to conceive how it can possibly do any good. 

Neuralgia of the tongue is a rare disease ; but, by a strange 
coincidence, a typical case presented itself to the writer when 
engaged in writing this brief article on diseases of the tongue. 
The only hope in this affection of any permanent relief will lie in 



844 

the persevering use of the remedies mentioned under Neuralgia, 
upon page 522. Beginning with large doses of quinine, combined 
with chloride of ammonium and a little morphine, the various anti- 
neuralgic agents should get a fair trial, while, by improving food, 
change of air, freedom from worry and other ills, the general health 
is brought up to the highest standard. A weak continuous current 
passed through the organ gives good results, if steadily adhered to, 
and relief has been known to follow even a few applications of the 
battery. 

Locally much may be done to afford ease. Cocaine dissolved in 
glycerin (12 grains to 1 ounce) may be tried, or tabloids of cocaine, 
or lozenges of carbolic acid. 

The writer has found the following combination give almost instant 
relief: 

R. — Cocaine hydrochlor. gr. xx. 

Glycerini boracis (1:6) ^j. — M. 

S. — A little of this liquid to be brushed over the tongue every hour or two 
hours during the day, and always a short time before taking food. 

In the instances of this affection which have come under the writer's 
notice, the pain was so much aggravated by movements of the tongue 
that the patients were compelled to keep it at rest, and this led to 
retained secretions filling the floor of the mouth. To prevent this it 
will be necessary to wash out the mouth frequently, and the best wash 
for this purpose is a weak carbolic acid lotion. Condy's fluid may be 
tried when there is any decomposition. The movements of the tongue 
may interfere with the feeding, and hence it is well to have the food ad- 
ministered in the liquid form. Section or stretching of the gustatory 
nerve may be resorted to when the ordinary anti-neuralgic remedies 
fail. 

The injection of various anodyne solutions, as morphine, etc., into 
the substance of the tongue is not to be recommended, but a full dose 
of the last mentioned drug may have to be administered under the 
skin below the lower jaw if the paroxysms of pain become very 
severe. 

Butlin recommends the local application of menthol. 

The peculiar condition of the tongue known under the various names 
of pso7*iasis, ichthyosis, tylosis, keratosis, and leucoplakia, and regarded 
by some authorities as of the same pathology as corns or callosities, 
give little satisfaction to the therapeutist. 

It resists drugs, and often resents interference of all kinds and 
finally may become the seat of a disease not to be distinguished from 
epithelial cancer. The keynote to treatment lies in the fact that this 
affection is often the result of the action of an irritant either in the 
form of a ragged decayed tooth, or it may be produced by smoking or 
drinking alcoholic liquids, probably both practices combined. Hence 



TONSILS — TOOTHACHE. 845 

the extraction of any irritating tooth or teeth, or the filing down and 
polishing of their crowns, and total abstinence from tobacco and 
alcohol should be insisted upon. Very hot liquids are likewise to be 
forbidden. 

Excision of the patch, when this is small, gives the best results, but 
all authorities are agreed that caustics only increase the mischief. 

The galvano-cautery may be used to advantage in some cases. 

Tongue tie is remedied by the simple ^operation of snipping the fre- 
num, which is generally resorted to much more frequently than is nec- 
essary. The most satisfactory method of operating is to pass in the 
index-finger and the next one under the tongue, the frenum being put 
upon the stretch between them, and, with a curved scissors, the point 
being held downward, the constricting band is divided by a single snip, 
care being taken not to divide the ranine vessels as the child struggles. 
For the treatment of Ranula see page 738. 

TONSILS. 

The treatment of inflammation and enlargement of the tonsils is 
detailed under Throat, Sore, upon page 832. 

TOOTHACHE. 

This is but a symptom of caries, periostitis, exostosis, impaction of a 
wisdom tooth, inflammation of the tooth-pulp, or other local cause, 
which must be carefully distinguished from neuralgia. When possi- 
ble, the cause is to be found out and remedied, but in the great 
majority of cases this will be found to be owing to irritation produced 
by caries. The cavity should be gently but thoroughly washed out, 
dried with a little cotton wool, and any of the following local anaes- 
thetics inserted into it on wool — creasote, carbolic acid, chloroform, 
oils of cloves, cajuput or peppermint. 

The packing of the pulp-cavity with drugs in the dry state is some- 
times resorted to. Thus cocaine, chloral, butyl- chloral, camphor, men- 
thol, morphine, opium, antipyrine, or exalgine, may be placed in the 
hollow, and kept in position by a little cotton wool loosely packed 
upon the top. The best results are obtained by injecting through the 
dead pulp cavity a little pure creasote or camphorated chloroform 
down into the hollows in the fangs. 

Where there is very severe pain originating in the living pulp of a 
carious tooth, the most satisfactory method will be to remove any 
stoppings, if such exist, or to gently remove any carious dentine until 
the pulp cavity is well exposed, and then by a minute quantity of 
powdered white arsenic left in situ by a plug of cotton wool the vitality 
of the pulp is to be entirely destroyed. Chloride of zinc and nitric 
acid or solid nitrate of silver may be used in the same way. 

Tomes points out that for the relief of p'ain a dead tooth should be 
left quite open, and a live tooth sealed closely up. This is seen where 



846 TORTICOLLIS. 

the pain results from pus in the pulp-cavity. No relief can be ex- 
pected until the pulp cavity is opened up and the matter evacuated, 
and further tension prevented by leaving a way for free exit. 

The best routine local anaesthetic for relieving the pain of an in- 
flamed pulp cavity is a mixture of carbolic acid and collodion. This 
obliterates sensibility, and seals up the chamber if applied carefully 
upon cotton wool. Cocaine may be combined with the acid. It will 
be remembered that this application should not be used to seal up a 
dead pulp cavity in a tooth where acute pain is produced by some in- 
flammatory action in the neighborhood of the tooth or in its roots. 

R. — Collodii . ' . . ^iij. 

Acidi carbolici (cryst.) . . . . . . ^iij. 

Cocainse kydrochlor. gr. x. — M. 

S. — A small portion to be applied upon cotton wool to the dried-out pulp 
cavity of the painful tooth. 

The popular remedies for external application are of little use, and 
the plan of rubbing aconite, belladonna, or chloroform along the gums 
does more harm than good. The anti-neuralgic remedies internally 
are also not to be relied upon as long as the local conditions remain 
unattended to. It is hardly necessary to insist upon the importance 
of saving the tooth. Extraction should only be resorted to when the 
disease in the tooth substance is too extensive to permit of the hope 
of a solid stopping being inserted after the subsidence of the acute 
symptoms. 

Chewing of pellitory root sometimes relieves the pain depending 
upon congestion of the fangs or of the periosteum. 

Extraction may be the only means of giving relief where the pain 
is caused by the impaction of a wisdom tooth. If possible, the wis- 
dom tooth itself should be removed, as it is generally much less valu- 
able than the molar in front of it, but this latter may have to be 
sacrificed if the wisdom tooth cannot be brought within the grasp of 
the forceps. 

TORTICOLLIS. 

As this condition arises from several distinct causes, the treatment 
cannot be commenced until the cause at work is thoroughly made 
clear. In those cases occurring soon after birth, where a hard tumor 
can be felt along the course of the sterno-mastoid muscle, the deviation 
of the neck is clearly owing to the rupture of the muscle during 
labor. The writer has seen a considerable number of these cases 
during many years' practice in the extern department of a children's 
hospital, and he has never] known an instance where the affection did 
not pas 5 away completely. Friction with any mild lubricating oil or 
the lin. potass, iod. cum sapone (B. P.), and the envelopment of the 



TOKTICOLLIS. 847 

neck in a thick collar of cotton wool, always was followed by disap- 
pearance of the tumor and of the deformity. 

Where wry-neck is spasmodic, it presents sometimes one of the most 
obstinate complaints that can come before the physician. This 
acquired form has been submitted to great variety of treatments. As 
a rule, it may be laid down that tenotomy is very seldom successful, 
and that very often it considerably aggravates the deformity. After 
dividing the tendon, various plans have been tried for fixing the head 
in its natural position, but such appliances are seldom successful. 

Levrat, after dividing the tendon of the muscle and suturing the 
wound, fastens a rubber band between hooks attached to a silicated 
bandage. This band is to assist the sound muscle to overcome by its 
continuous action the opposing one. It runs in the direction of the 
muscle from the mastoid to the axilla of the same side. 

Stretching or resection of a portion of the spinal accessory nerve 
has succeeded sometimes in spasmodic torticollis, but it has also failed. 
The operative treatment of the spasmodic variety being, therefore, so 
unsatisfactory, it never should be entertained until other measures 
have failed. The mere adjustment of an apparatus with the view of 
tiring out the opposing muscle has been tried, and in a few cases has 
been tried, and in a few cases has succeeded, but, as a rule it fails, 
and during the period in which it is tried the patient often suffers 
great discomfort. 

Electricity or galvanism has given excellent results in many cases, 
and if resorted to early there may always be a fair hope of success. 
It must, however, be persevered with for some time. There are various 
plans for using this agent. The best is to begin with a very mild 
continuous current to the affected or constantly contracting muscle for 
fifteen minutes three times a day, and when the spasm is controlled, 
to educate the patient to use the affected muscle in various ways, as in 
turning the head in different directions. Fifteen Leclanche cells will 
suffice, with one pole (the positive) near the mastoid bone and the 
other near to the clavicle. 

The opposing muscle is generally found weak, and it should have 
the interrupted current passed through it from time to time, in order 
to cause lively contractions, massage being employed twice a day. By 
increasing in this way the tone and power of the weakened antagoniz- 
ing muscles, and controlling or modifying the spasm iu the affected 
sterno-mastoid and other muscles, great good or permanent cure may 
be obtained in a fair percentage of cases. This plan has succeeded 
admirably in the writer's hands. 

Bromide of potassium in large doses, with arsenic internally, may 
be always tried, and some cases have been reported as cured by the 
hypodermic injection of gelsemium after tenotomy or myotomy had 
failed. Weir Mitchell recommends very large doses of this latter 
drug, so as to produce very pronounced physiological action. He 



848 TEANCE. 

begins with 3 minims of Wyeth's fluid extract three times a day, until 
eight times this amount is taken. 

Curare and morphine have been injected, conium given in large 
doses, and hyoscine administered, but their effects rapidly pass off. 
They may be used, however, to great advantage when other means, as 
galvanism are having a trial. 

In those cases of torticollis following old disease of the bones in the 
neck, tenotomy is generally of much value. The tenotome is entered a 
little above the clavicle, and both portions of origin may require to be 
cut. After the wound has healed exercises are to be commenced and 
carried out with great persistence, while massage is to be done two or 
three times daily. 

Lately many surgeons have reported successful cases after division 
of the tendon or muscle through an extensive skin wound. Summers 
makes his incision parallel to the clavicle, but does not suture the 
wound. Collier reported recently a very interesting and successful 
case in which he cut down and placed a loop of silver wire upon the 
spinal accessory, twisting the ends to insure slight compression, and 
leaving the ends of the loop protruding from the wound. 

TRISMUS— See Tetanus Neonatorum, page 830. 

TRANCE. 

Under Hysteria, on page 382, the treatment, moral and medicinal, 
for the condition which generally underlies trance will be found. If 
the state of trance be not very " deep," the treatment described under 
catalepsy will be successful. Electricity in the form of a strong inter- 
rupted current should be used in all cases, and when there is any 
evidence of a return to half-consciousness the battery should be at 
once applied to the arms and legs. Snuff, strong ammonia, nitrite of 
amyl, etc., may be used at the same time, but they are of little value 
in genuine trance. When these measures are used at the same hour 
each day, as Gowers recommends, there may be induced a tendency to 
periodical waking, which will ultimately culminate in a cessation of 
the attack. Until then every attention must be paid to the maintenance 
of life. Feeding should be carried on by the rubber tube of the 
stomach-pump, introduced through the nose or mouth. 

Rectal alimentation may be essential also in prolonged cases. Strong 
tea and coffee are indicated. 

By the judicious application of warmth and skilful nursing much 
may be done to minimize the exhaustion sure to follow, especially in 
those case where food cannot be administered. 

Antispasmodics, as bromides, musk, valerian, asafcetida, sumbul, and 
other anti-hysterical agents, may be given by the bowel or by the nasal 
tube, but they do little good, and the first mentioned drug may do 
harm. 



TRICHIASIS — TRICHINOSIS. 849 

Reasoning from the observation that strychnine so often aggravates 
the abnormal sensations complained of by the hysterical patient, the 
writer believes that the best drug treatment in this affection may be 
found to be the steady administration of strychnine by the hypodermic 
syringe with the view of increasing the sensitiveness of the nerve 
centres and the peripheries of the sensory nerves and nerves of special 
sense. 

TRICHIASIS— See under Entropion (page 244). 

Epilation of the irregularly growing hair may be all that is required 
in mild cases to give temporary relief, but as the hair grows again the 
trouble is almost certain to return. 

The hair-bulbs must be destroyed. This is most easily accomplished 
if there are but a limited number of them producing the mischievous 
lashes by inserting a needle into the hair follicle, connecting it to the 
negative pole of a battery, while the positive pole is placed over the 
skin in the vicinity of the eye. 

Where a considerable number of the hairs are at fault, the best plan 
is to make two parallel incisions along the margin of the lid, and to 
carefully dissect out the hairs and their hair bulbs. 

The operation of transplantation is to be performed when the entire 
row of hairs is faulty ; it is done by splitting the lid along is marginal 
surface between the hair-bulbs and the Meibomian follicles and excising 
an elongated or elliptical piece of skin from the outer margin of the 
eyelid and fastening the- cut surfaces by sutures, so as to draw away 
the ingrowing hairs (page 244). 

TRICHINOSIS. 

The preventive treatment of this serious disorder is practically all 
that need be considered, as we know of no agent which will destroy 
the parasites once they have become encapsuled in the muscles. In the 
case of food it is satisfactorily proven that there is no chance of the 
disease being communicated if the cooking has been very thorough, 
it must be remembered that trichinae may find their way into the human 
body not only from the uncooked flesh of the pig, but also from that 
of eels and pigeons. A temperature of 160° F. will destroy the para- 
site, but it will resist freezing "for considerable periods, and the process 
of curing by the ordinary brine solutions has no effect whatever 
upon it. 

After the ingestion of trichnized food in the stage in which nausea, 
vertigo, diarrhoea, and fever are present, the best treatment will be to 
clear out the stomach by means of a good emetic, followed by a large 
dose of some smart purgative, as 1 or 2 ounces of castor oil, 10 or 20 
grains of calomel, or 2 or 3 ounces of black draught or white mixture. 
These can be repeated for five or six days or more. Fever is afterward 
to be combated by the administration of small doses of antipyrine, and 



850 TUBERCULOSIS. 

every effort made to keep the patient's strength supported by means of 
absolute rest in bed and by feeding with peptonized foods, in order to 
tide him over the period of acute danger, while the progeny of trichina 
— embryos — are migrating into the muscles. Rectal feeding may be 
necessary, and free supply of stimulants are called for in some cases. 

The administration of anthelmintics or of antiparasitic agents, like 
arsenic, picrate of potassium, corrosive sublimate, salicylates, and other 
powerful drugs may do much harm, but can do no good, and by uni- 
versal consent their use is now discontinued, reliance being placed upon 
supporting treatment. 

TUBERCULOSIS. 

Under Phthisis the treatment of tubercle has been fully detailed 
without any reference to the recent method introduced by Koch. The 
present article will occupy itself with this agent. Owing to the intense 
public and professional interest taken in Koch's remarkable researches 
in the therapeutics of tuberculosis, and to the bitter disappointment 
which soon followed, it will be many years before the memory of the 
excitement of this brief period in the history of medicine will be 
effaced. At the present moment most medical men and many patients 
and their relatives look back upon it as upon a huge nightmare. By 
many the remedy is considered to be so thoroughly discredited that any 
lengthened reference to it will be deemed a waste of time, and since 
the details of the experiments which led up to its discovery, as well as 
those which have led to its abandonment, are now fresh iu the minds 
of everyone, there is no necessity in repeating them here. 

The lymph or " tuberculin " of Koch is a glycerin extract prepared 
from pure cultivations of the bacilli of tubercle. 

As supplied to the profession^, this brown liquid is estimated by Koch 
to contain only about 1 per cent, of the dry active principle, though in 
this form it is one of the most powerful agents known. There is much 
confusion about the strengths of the solutions. 

Unfortunately if the solution be made of the proper strength for 
injecting it will not keep for any length of time. First, a solution of 
pure carbolic acid in distilled water, 1 : 200, is prepared ; 1 part of 
Koch's lymph is added to 9 of this, making a 10 per cent, solution, 
which, though too powerful for use, will keep for a long time, and can 
be diluted as required. This 10 per cent, solution of the original 
lymph is known as the " mother solution " — an unhappy nomencla- 
ture, since Koehler speaks of the original lymph as the " mother 
liquid " — 1 part of this solution added to 9 parts of distilled water 
makes the solution which is used for injection. This dilute standard 
solution, therefore, is a perfectly clear 1 per cent, solution of the origi- 
nal liquid lymph or tuberculin. The dose of this is always given in 
the metric phraseology, with which most English physicians are not 
familiar, and hence mistakes or confusion arises, especially as many 



TUBERCULOSIS. 851 

authorities speak of the dose of this standard 1 per cent, solution in 
milligrammes, while others speak of it in cubic centimetres. In deal- 
ing with an agent of such terrible potency there should be no ambiguity 
about our nomenclature. The milligramme is a metric weight corre- 
sponding to 0.015432 of our English grain, being the one thousandth 
part of a grauime (which latter corresponds to 15.432 English grains). 

A cubic centimetre (written c.c.) is a metric measure of capacity, 
being a millilitre or the measure of one gramme of water. Our minim 
is equal to 0.061 c.c. One c.c. will, therefore, correspond to- 16.23 
minims. 

This confusion of weights with measures, to be noticed in many of 
the papers on Koch's lymph, arises from the universal practice in 
Germany, France, and Russia, of dispensing or compounding all 
liquids by weight, not by measure, as is our invariable rule in Great 
Britain. 

Koch's syringe obviates the difficulty of translating the metric meas- 
ures in their English representatives, as it is graduated in a manner to 
be presently described. Each division of the syringe corresponds to 
one decigramme, the ten divisions marked on the syringe making up 
one c.c. Roughly, each decigramme may be taken as representing li 
minims. 

As pointed out by Koch in his original paper, the injection of 0.01 
c.c. of the original lymph, or 1 c.c. of the standard 1 per cent, solu- 
tion, produced scarcely any symptoms when injected into healthy 
individuals, but always a marked reaction characterized by a sharp 
rise of temperature and other signs when injected into any patient 
containing tubercle in his body. This remarkable phenomenon was 
considered as introducing a new method of diagnosing tubercle, and, 
though several exceptions have been recorded, it cannot be yet denied 
that it may render manifest tubercular disease not otherwise discover- 
able. The idea of utilizing such a terribly potent poison for such a 
purpose is another matter, and we may safely prophesy that it will be 
seldom used for this purpose in this country. 

In treating tubercle of the lung or ordinary phthisis in weak or 
young patients by means of this agent it will be well to begin with the 
smallest dose. This is 0.001 c.c. of the original lymph, or 0.1 c.c. of 
the 1 per cent, solution. This corresponds to 1 milligramme, or about 
-^ grain (English) of the original lymph, or to one-tenth of a cubic 
centimetre of the 1 per cent, solution (i. e., to II grains). The writer 
mentions the equivalents in each case, because in many of the reports 
the observers hopelessly muddle up the quantities or doses of the 
original with those of the 1 per cent, solution. 

In strong, robust subjects double this dose may be given, and in lupus 
cases ten times the amount may be administered. (Ten times this 
initial dose just stated will represent 1 c.c. or 15.432 grains of the 
1 per cent, solution.) Having commenced with the minimum dose of 
0. 1 c.c. of the 1 per cent, solution, it is to be daily repeated until the 



852 TUBERCULOSIS. 

temperatnre ceases to be affected. It is then doubled until the tem- 
perature ceases to rise, after which it is again increased by 1 or 2 
milligrammes each time until the full dose of 0.01 c.c. of the original 
lymph, or 1 c.c. of the 1 per cent, solution, is injected. 

Koch's syringe is made to contain 1 c.c, and is graduated in deci- 
grammes, each of which will represent a dose of the original lymph, 
equal to 0.001 c.c. when the syringe is filled with the 1 per cent, solu- 
tion. When the very large doses are reached the 10 per cent, solution 
may be used. Every milligramme of it will correspond to 0.01 c.c. 
(the maximum ordinary dose). Large doses are used as "test doses." 

The injections are to be made into the skin over the back between 
the scapula?, the syringe being each time sterilized by washing with 
absolute alcohol. The needle should be washed in a 1 : 20 carbolic 
solution, and the skin in the region of the puncture should be well 
washed with ordinary carbolic lotion. In early lung tubercle a period 
of about four to six weeks completes the treatment. The temperature 
after injection begins to rise in three or four hours, and the highest 
point is reached in a about twelve hours, the normal being touched 
generally inside the twenty-four hours after the injection of the remedy. 

Speaking of the dose of the original lymph, Koch states in his paper, 
November, 1890 — "Our course was generally as follows: An injection 
of 0.001 c.c. was first given to the phthisical patient. On this a rise 
of temperature followed, the same dose being repeated once a day until 
no reaction could be observed. We then rose to 0.002 c.c. until this 
was borne without reaction, and so on, rising by 0.001, or at most 0.002, 
to 0.01 c.c. and more. This mild course seemed to me imperative in 
cases where there, was great debility. By this mode of treatment the 
patient can be brought to bear large doses of the remedy with scarcely 
a rise of temperature. But patients of greater strength were treated 
from the first partly with larger doses, partly with rapidly repeated 
doses. Here it seemed that the beneficial results were more quickly 
obtained. Within four to six weeks patients under treatment for the 
first stage of phthisis were all free from every symptom of disease, 
and might be pronounced cured. Patients with cavities not yet too 
highly developed improved considerably, and were almost cured. 
Only in those whose lungs contained many large cavities could no 
improvement be proved objectively, though even in these cases the 
expectoration decreased and the subjective condition improved. These 
experiences lead me to suppose that phthisis in the beginning can be 
cured with certainty by this remedy" 

Regarding the treatment of lupus and tubercular disease of bones 
and joints, Koch began at once with the full dose of 0.01 c.c. of the 
original lymph (that is, 1 c.c. of the 1 per cent, solution), and, after 
allowing the reaction to come to an end, in a week or two, he injected 
the same dose until the reaction ceased to appear. The writer has 
witnessed most formidable and dangerous symptoms follow this dose in 
lupus. 



TUBERCULOSIS. 853 

Soon after the treatment of Koch had been extensively tried, it was 
clearly pointed out by Virchow and others that development of fresh 
tubercles occurred in various parts of the body, and innumerable 
deaths have been recorded which clearly prove that after injection 
the bacilli were set free and produced a general tuberculosis. In 
one case of lupus in which the writer gave the remedy a very 
prolonged trial, tubercular disease followed in one of the bones of 
the hand. 

It is not stating the case too strongly to say that at the present date 
the very general conviction remains in this country, and also in the 
minds of most of the leading physicians on the Continent, that the 
lymph is thoroughly discredited, and has proved an absolute failure. 
Many impartial observers go so far as to state that its use is unjusti- 
fiable or even criminal. 

The discovery of an agent of such marvellous and almost incredible 
selective power will nevertheless mark a distinct epoch in the history 
of medicine. 

The writer has watched the action of the drug closely, and though 
he is satisfied of its failure and danger in every instance in which he 
has used it or seen it used, save in one case, he ventures to enter 
a mild protest against the present prevailing condemnation. It must 
be fairly borne in mind that the agent has demonstrated its selective 
action upon the tissues containing tubercular bacilli, and the innu- 
merable failures have followed what, after all, has been the original 
plan of Koch for the administration of the drug. It is true his plan 
of using the lymph has been modified to some extent by some observ- 
ers, but, as a whole, it may be said still to have always been used 
upon the lines laid down first by its introducer. 

Without going into the various theories and explanations of its 
selective action, and the elucidation of how the phenomena of reac- 
tion are produced, the writer will presume to suggest that a case can 
be made out for the further trial of Koch's tuberculin with a fair 
prospect of success. At the beginning, let it be understood that the 
proposition is based purely upon theoretical considerations, and that 
these theories have at least a very large proportion of solid facts to 
sustain them. In the proposition which he will make he will en- 
deavor to differentiate between theory and fact as far as possible. It 
may be taken as granted at the start that the tuberculin exerts no 
power over the bacilli. Koch himself states — ■" But so much is cer- 
tain that there is no question of a destruction of the tubercular bacilli 
in the tissues, but only that the tissue enclosing the tubercle bacilli is 
affected by the remedy." 

It may be also accepted that the danger and failure of his plan of 
treatment of established phthisis lies in the fact that the bacilli are 
freed from the tissues, and find their way by the fluids of the body 
into its various parts. 

The discovery by Metschnikoff of the phenomenon to which he gave 



854 TUBERCULOSIS. 

the term " Phagocytosis," is one of the most brilliant and valuable in 
the annals of science. His paper, " Uber eine Sprosspilzkrankheit 
der Daphnein. Beitrag zur Lehre iiber den Kampf der Phagocyten 
gegen Krankheitserreger," appears in the Archiv of Virchow, 1884. 

That phagocytosis occurs in many instances where disease germs are 
introduced within the body is beyond doubt. The writer satified him- 
self of the accuracy of Professor Metschnikoff's researches in the living 
daphne, and of his wonderful observations upon various stages of the 
process occurring in several human diseases by an examination of the 
specimens kindly exhibited by the professor in his laboratory at the 
Pasteur Institute. The demonstration left nothing to the imagination, 
the specimens proving beyond a shadow of doubt the various steps by 
which the living cells manage to seize the bacilli and effect their com- 
plete destruction. 

The most striking point in connection with this question is the fact 
brought out by many independent observers regarding the action of 
the white blood-corpuscles and other cells in animals protected by pre- 
vious inoculation, and in those not so protected. If the anthrax bacilli 
be introduced into a healthy, unprotected rabbit there is practically no 
attempt made by the phagocytes to include them. The bacilli increase 
and multiply in the blood and destroy the animal, the amoeboid cells 
remaining neutral. 

A very different state of matters is to be seen when the bacilli of 
anthrax are introduced into a rabbit previously protected by an inoc- 
ulation of the chemical substance prepared from anthrax cultures. 
The rabbit with this acquired immunity is safe. As soon as the living 
bacilli are injected the amoeboid or white blood cells in great num- 
bers move toward the seat of injection, and include (devour) the 
bacilli which are to be seen in their interior in various stages of 
dissolution. 

It has been demonstrated by Metschnikoff and witnessed by th.e 
writer that the amoeboid and giant cells include the bacilli of tubercle 
finding their way into the human body. 

It is not too much to assume that it is by this process of phagocytosis 
going on in man that the majority of individuals are protected from 
tubercle, the bacilli of which must be finding their way into the body 
in myriads from the dust of cities whose streets are continually soiled 
by the sputa of phthisical patients. 

It is useless to theorize upon the solution of the problem of why 
phagocytosis is successful in the majority of individuals and why 
it fails in the minority. Probably some attempt is made at it in all 
cases. 

This consideration brings us to the next important step in the sug- 
gestion of the treatment of tuberculosis by a different method of employ- 
ing Koch's lymph. Does the injection of this agent tend to protect 
against a subsequent inoculation of the bacilli of tubercle? Much 
hangs upon the answer to this question. The results published by 



TUBERCULOSIS. 855 

Graucher aud St. Martin prove that it is easy to protect rabbits by 
inoculations of attenuated tubercular virus ; and there is a large mass 
of evidence, including that from Koch himself, which goes to prove 
that healthy animals can be certainly to a very great degree, if not 
entirely, protected by injections of sterilized cultures. These results 
are, however, denied by others. 

It is, however, not yet proposed that healthy subjects would be 
submitted to protective injections. The bearing of acquired immunity 
or protection in the case of patients having isolated foci of bacilli of 
tubercle somewhere stowed away in their tissues is a vital one. 1 

The tubercular bacilli shut up in the interior of the tissues, say of a 
lymphatic gland, may be regarded as outside the blood stream in a 
certain sense. We know from clinical experience that they may 
remain there, as they do in lupus, for half a century without any 
risk of general infection. We know also, in the sad experiences of 
the last twelve months, that Koch's lymph, if administered in the way 
recommended, will render the tissue surrounding the bacilli necrotic, 
and the speedy result will be that the bacilli are thrown into the 
blood stream and set up a general tuberculosis or are carried to other 
organs. 

JSTow, the contention of the writer is that each injection of a full 
dose of Koch's lymph in such a case may be regarded for all practical 
purposes as an injection of living tubercular bacilli into an unprotected 
animal. The human subject in the early or middle stage of pulmonary 
or ether form of tuberculosis is, after each injection, in practically the 
same state as an unprotected rabbit into whose blood living tubercular 
bacilli had been injected. We know that phagocytosis does not take 
place, the bacilli set free from the tubercles by the "lymph" are not 
attacked by the phagocytes, and in the great majority of cases the state 
of the patient may be worse than before. 

If the condition of the patient before the injection of the tuberculin 
could be - made to correspond with that of a protected rabbit, then 
there would be hope for the success of the treatment of phthisis and 
other forms of tuberculosis by the injection of the new agent. 

The writer believes this to be possible. Given a patient with the 
bacilli of tubercle locked up in tubercles in his lung, if the present 
state of our knowledge is correct, small — very small — doses of Koch's 
lymph should be given for a considerable time, say weeks, after which 
he is probably pretty well protected. Then a few large doses should 
be given, so as to produce well-marked reaction. The tissues surround- 
ing the bacilli will be acted upon, and these, as they become liberated, 
will find their way into the blood stream, where they will be attacked 
by the amoeboid cells and destroyed. 

1 In the ordinary use of the term, it is hardly correct to speak of acquiring 
immunity from a disease already existing, but the sense in which this is now used 
will be apparent further on. 



856 TUBERCULOSIS. 

By the small preliminary doses the organism is changed, so that ths 
amoeboid cells, instead of running away from the bacilli, as they do 
under the usual injections, will enclose them as they do in the case of 
an animal who has undergone the process of acquired protection. 

The failure of Koch's treatment may, therefore, possibly be owing 
to the doses employed. The discoverer of the selective action of the 
tuberculin always aimed at producing "reaction" by using very large 
doses. 

Instead, therefore, of commencing the treatment of a preliminary 
phthisis, lupus, or joint affection with g- 1 ^ or y 1 ^ grain of the original 
lymph, the writer would suggest two daily doses of -not more than 
the -2T0 grain ( this would be equal to half a minim of the 1 per cent, 
solution) for two or three weeks, or longer. One-thirty-second grain 
might then be given — i.e., \ c.c. of the 1 per cent, solution, and if 
marked reaction did not occur the dose should be rapidly increased. 

The action of the large dose, if such a method succeeded, might be 
likened to that of a ferret dislodging vermin from their holes in order 
to be devoured by an army of terriers stationed outside. The sug- 
gestion is based upon a study of the various researches recently con- 
ducted in bacteriology, and though it may break down in practice, 
nevertheless any plea for the further trial of this agent which possesses 
such certain and wonderful selective action is opportune in the present 
state of disappointment, when there is danger of its passing entirely out 
of use in practice. It is clear that its dosage and actions have not yet 
received the attention to which they are entitled. Looking to the 
future of the bacteriology question, it seems very probable that phago- 
cytosis must receive marked attention. 

One case in which the writer was satisfied that Koch's treatment 
effected an apparent cure was treated in an Alpine resort during the 
period of injection. It is just possible that the result was produced by 
an increased vitality in the amoeboid cells induced by the altered 
environment. 1 

Professor Le Peine, of Lyons, was led to try the effects of injections 

1 Since the above was written, the brilliant researches of Cheyne and W. Hunter 
have been recently published. Both observers are satisfied that injections of 
Koch's tuberculin do not confer immunity. They have demonstrated the impor- 
tance and necessity of a further study of the therapeutics of this powerful agent. 
Their researches and experiments clearly prove that tuberculin is a composite 
substance, and they have been able to demonstrate that it is comparatively easy to 
separate the remedial from the fever-producing substances. Cheyne has estab- 
lished what the writer has but feebly attempted — viz., he has clearly demonstrated 
the necessity of a further trial of this discredited agent. The concluding sentence 
in his last paper may be quoted : " I cannot but think that the result of the getting 
rid of the noxious constituents of tuberculin will be to place this treatment in a 
prominent position among the means at the disposal of the physician, and I look 
to the work of physicians for the final determination of the place which these sub- 
stances shall occupy in the lists of remedial agents for tuberculosis." — British 
Medical Journal, August 8, 1891. 



TUBERCULOSIS. 857 

of the blood of the goat in phthisical patients from a consideration of 
the great rarity of the disease in these animals, and the results at one 
stage of his observations promised well, but in an interview recently 
with the writer, he stated that he had given up the research, at least 
for the present. 

Professor Reichet has been making an exhaustive study of the action 
of the serum obtained from the dog. He has had this injected by an 
ordinary hypodermic syringe under the skin in doses of about 15 to 30 
miuims in phthisical patients and those suffering from lupus. The 
writer, who has studied the preparation of this agent in the laboratory 
of the professor in Paris, and has seen its effects on lupus in Professor 
Fournier's wards, was deeply impressed with the results. The remedy 
is, however, only upon its trial, and the distinguished professor to whose 
great kindness the writer is deeply indebted, will in due time give the 
results to the medical world. The recent work done by a large number 
of bacteriologists goes to show that there may be very great bactericidal 
properties residing in the body humors, and the action of an agent like 
dog's serum injected even in small quantities, may achieve results 
which would seem almost impossible to those who have not been 
watching the march of events in this particular field of experimental 
research. It is possible that good results maybe obtained from a com- 
bination of the new methods. 

Liebreich has been testing the action of another new tubercle cure, 
and various reports have (as is always the case) been already forth- 
coming of cures achieved by the new agent. This is cantharidinate of 
potassium, the dose of which by hypodermic injection is 1 to 2 deci- 
milligrammes — i. e., -g-^g- to -g-^- grain. Serum is exuded from the 
capillaries throughout the body after this agent has been introduced 
into the blood ; and Liebreich believes that this exudation may work 
in two ways : 1. By suj^plying increased pabulum to badly-nourished 
cells, these may be brought back to the healthy standard ; 2. It may 
act beneficially by its disinfecting action on the diseased spot. He 
states, "That if it can be proved that in cantharidin we possess a 
means of producing an increased secretion of serum at any one spot, 
we may succeed in concentrating at this spot efficacious substances, 
which, under ordinary circumstances, do not easily find their way there. 
"We know substances that circulate in, and are decomposed by the blood, 
but which only with difficulty pass through the kidneys. But if we 
know that at an affected spot the exudation from the capillaries is 
facilitated, we can imagine that a larger quantity of an efficacious sub- 
stance may find its way to this spot, thus strengthening the otherwise 
feeble disinfecting power of the serum. It seems to me not unlikely 
that such a combination of two remedies might possibly lead to a new 
therapeutic method. As regards practical application, special attention 
should be paid to the kidneys. It is clear that this treatment should 
not be applied where there is disease of the kidney." 

Tranjen has introduced a new method of treating tuberculosis which 



858 TUBERCULOSIS. 

has been approved of by Ewald. It is a solution of hydrargyrum 
thymolo-aceticum injected into the muscles of the buttock every eight 
days. After a few injections, a solution of iodide of potassium is 
given by the mouth — 3 grains thrice daily. 

Just at the present moment the new method introduced to the notice 
of the French Academie de Medicine by Lannelongue is occupying 
the attention of physicians. One may predict at first sight that it is 
not likely that this plan of treatment will prove successful in visceral 
tuberculosis, but the lookout is very hopeful as regards its utility in 
destroying the tubercular process in other regions of the body. He 
defines it as a method of prompt transformation of tuberculous 
products in the joints and certain other parts of the human body. It 
consists in the deep injection of dilute solutions of chloride of zinc into 
the tissues surrounding tubercular deposits in order to induce a condi- 
tion of sclerosis which proves fatal to the existence or growth of the 
bacilli. 

The effects are stated by Lannelongue to be a " fixing " and " kill- 
ing" of the anatomical elements of the tissues into which the remedy 
penetrates, an obliteration of some of, the capillaries and smaller ves- 
sels and a diminution in the calibre of the arteries and veins by setting 
up an inflammatory irritation in their walls. He states that an enormous 
proliferation of new embryonic cells takes place, not only at the seat of 
injection, but for some distance around it. These infiltrate the tuber- 
culous tissue, and he believes attack and destroy the bacilli. (This 
may be proved afterward to be a local process of phagocytosis.) 

The morbid " fixed " tissue becomes slowly absorbed, while the young 
cells rapidly pass into the condition of new fibrous structure. In the 
report of the communication made to the Academie as it appears in the 
British Medical Journal of last July, the following results are detailed : 

"The injections cause considerable local pain and swelling, but, 
as a rule, no cedema if they have been made sufficiently deep ; the 
integument is brought into a condition resembling the sclerema of 
newborn infants. In two or three days the granulation tissue is more 
resistant and more tense to the touch, and soon afterward nodules of 
almost cartilaginous hardness can be felt at the seat of injection. In 
course of time there is a tendency for the sclerosed tissue to become 
looser and more like connective than fibrous tissue. In this way the 
parts may recover their natural shape and suppleness. The treatment 
has little or no effect upon the general health. The temperature, as a 
rule, rises less than 1° C. after each injection, and soon returns to the 
normal point. Of 2000 injections given during the last seven or eight 
months, not one has given rise to abscess, but in four cases they were 
followed by hematoma, which M. Lannelongue believes to have been 
due to rupture of small vessels due to the irritation caused by the 
chloride of zinc. No eschar is produced if the injections are made 
into or under the muscular layers. For tuberculous disease of the 
joints, ribs, etc., and for tuberculous^glands, he recommends the use of 



TUMOKS — TYLOSIS. 859 

a 1 : 10 solution, 2 drops to be injected in a number of places around 
the periphery of the diseased part. Suppurating glands should be 
washed out with an abundance of sterilized water, and in all cases the 
injections should be made with the most rigid antiseptic precautions. 

" In tubercle of the epididymis and in spina ventosa, a 1 : 20 solution 
was used ; two or three drops of a 1 : 40 solution were injected into the 
lungs. So far M. Lannelongue has treated twenty-two patients by his 
method, some of whom he showed to the members of the Academic 
All of them were under fifteen. Twenty of them were suffering from 
osteo-arthritis of the limbs or spinal column, or from tuberculous 
glands, both non -suppurating and suppurating, and in some cases 
open. Tw t o were suffering from tuberculosis of the lung. Of the 
former series several may be considered cured, and in all, the morbid 
process has been favorably modified ; as regards the pulmonary cases 
they have not been long enough under treatment for any reliable con- 
clusion to be arrived at." 

The plan of treating tubercular abscesses and joints by aspiration 
and injections of iodoform emulsion as practised by Bruns, Krause, 
Billroth, Trendelenburg, and others, is described under Abscess, page 15. 

Our recent painful disappointment in the results of Koch's method 
naturally renders the acceptance of the newer methods with an unusual 
amount of hesitation and scepticism, but it seems hardly possible to 
conceive how great progress can fail to be very soon recorded in this 
particular portion of the domain of therapeutics, when we consider the 
ceaseless activity displayed by the most original minds in our pro- 
fession, all working toward this one goal — the destruction of the 
tubercular bacilli. 

TUMORS. 

Under various headings the treatment of tumors are referred to 
throughout this volume, as under Ovary, Diseases of; Spina Bifida, 
Lymphatic Glands, Nsevi, Hydatids, Cancer, etc., so that any general 
remarks here are unnecessary. 

The removal or non-removal of tumors, both innocent and malignant, 
and the best methods for removal in each particular case, are to be 
laid down upon general surgical principles, after the anatomical and 
clinical peculiarities have been fully recognized. 

TYLOSIS. 

Where the increased or hypertrophied epithelium in situated upon 
the skin, the treatment to be adopted is that noticed under Corns and 
Callosities, page 152. In tylosis of the tongue, the measures detailed 
under Tongue Diseases, upon page 844, are indicated. 



860 TYMPANITES — TYPHOID FEVEK,, 

TYMPANITES. 

The treatment of this symptom will depend entirely upon the causes 
producing it. The treatment of these has already been detailed under 
their various headings, so that no further notice here is necessary. 
The reader is referred to the articles upon Dyspepsia, Intestinal 
Obstruction, etc. 

Where the causes are not removable, agents may be employed in 
each case suitable to the condition of the patient. Thus, in hopeless 
cases of abdominal obstruction from cancer, where colotomy or other 
operation is contra-indicated, the abdominal wall and intestines may 
be pierced by a fine aspirator-needle, and the imprisoned flatus let free. 
As a rule, this affords but little relief. A much better plan is to make 
a small opening in the middle line, and, having secured the first coil 
of distended bowel presenting, to open this and leave it in situ in the 
abdominal wound. Elsewhere the writer has stated his experience of 
the uselessness of the long tube introduced into the rectum, Enemata 
of turpentine, creasote, asafoetida, and the internal administration of 
these agents at the same time, alone or combined with galbanum, 
musk, ammonia, alcohol, charcoal, ginger, capsicum, cajuput, pepper- 
mint, etc., may be tried. 

TYPHLITIS. 

The treatment of this condition will be found detailed under Peri- 
typhlitis, upon page 612. 

TYPHOID FEVER. 

There are few diseases in the entire range of medicine in which so 
much has been done to reduce the mortality as in the affection under 
notice. 

It will be seen, however, that not in drugs, but in skilful nursing, 
dieting, and other measures, is our faith to be centred. At the outset, 
it will be recognized that the seige may be a very long one, and 
arrangements must be made accordingly. Perhaps there is no single 
factor, or combination of factors, of such vital importance in the treat- 
ment of typhoid fever as the 'period or stage in the disease at which the 
case is placed under treatment. The earlier the stage in which the 
measures about to be described are brought to bear upon the patient 
the greater is the probability of a successful issue. 

The sick-room should be selected by the physician, and it should be 
quiet, well ventilated, large, and airy, with abundance of light, which 
can be easily cut off when desired. Where a very large room can be 
obtained, it should be selected, even in winter, and by a few screens 
placed around, but at a distance from the bed, an agreeable aspect of 
comfort can be easily produced. 

Jenner's plan of having two rooms — one for the night and one for 
the day — is theoretically a good one, but in practice a dangerous one, 



TYPHOID FEVER. 861 

owing to the serious consequences which may arise from moving the 
patient about. It may, however, be adopted in those cases where two 
good rooms open directly into each other, the patient and his bed being 
carried (not rolled) from the one to the other. An upstair room is 
preferable (this is most desirable in typhus), and the question of 
having an open fire night and day will be settled by the state of the 
weather, etc. 

There should always be two moderately small beds, of precisely the 
same height from the floor, so that, when drawn up exactly alongside 
each other, the patient can be shifted from the one to the other more 
safely than from one part of a large bed to the other. There is nothing 
so good as a firm straw palliasse, with a good hair mattress upon the 
top. A wire mattress instead of the straw palliasse is preferred by 
some as being cooler, but it lacks in firmness. The bed should be so 
placed — not in a corner — as to permit of the nurse and physician being 
able to walk all round it. Everything in the shape of hangings is to 
be forbidden. The bed-clothing must be light, and it is a good plan to 
replace the ordinary counterpane by a linen sheet, which can be fre- 
quently replaced. Mackintosh sheeting underneath is to be regarded 
as a very questionable adjuvant. 

The services of two good, skilled nurses — one for the day and the 
other for the night — are to be secured when possible, and it should be 
insisted that they regularly keep up a written report or journal of the 
temperature, bowels, doses, nourishment, etc. 

In summarizing the effects of different treatments, and in arriving 
at a conclusion about the advisability of altering any of the details of 
treatment in a case, it is essential for the physician to have a chart 
before him giving him a graphic or bird's-eye view of the variations 
in the temperature, etc. 

The patient is to be put to bed at the earliest possible moment, and 
from thenceforth until convalescence a position of absolute rest is to 
be maintained throughout his illness. The bed-pan and the urinal 
must be used always. Cases where perforation, hemorrhage, and death 
have followed the exertion of the patient's getting up to the night-chair 
are numerous. 

A draw-sheet should be constantly worn, and the most scrupulous 
cleanliness insisted upon. It is a good plan to have the motions disin- 
fected by some strong antiseptic, as chlorinated lime, terebene, etc., as 
soon as they are passed. One of these may be placed in the urinal 
each time before being used. 

Diet is of the utmost importance ; indeed, except, perhaps, in the 
case of diabetes, there is no affection in which the question of dietary is 
of such vital importance, and the young physician must recognize that 
there is no point in connection with this subject which he can afford to 
regard as too trivial for his consideration. Few men can be in practice 
long without being able to testify to the disastrous or fatal consequences 
which occur from the patient's indiscretion in this matter. A good 



862 TYPHOID FEVER. 

rule to have ever before the mind is to forbid every form of food all 
through the attack, except such as would readily pass through the meshes 
of a fine sieve. Not that it will be necessary to sift any food, but to 
have clearly before the mind of the patient and nurse that only sub- 
stances in the liquid form or those containing impalpable powders are 
admissible. 

Milk meets all requirements in the vast majority of patients, and 
when they can take it, which is nearly always the case, there need be 
little trouble about the dietary in the early and acute stages of the 
disease. It is needless to say it should be of the purest and sweetest. 

The quantity should, for adults, be not less than three or four pints 
in the twenty-four hours. Some patients will be found who can take 
and digest twice this amount, "and when very large quantities are taken 
it may be advisable to skim it occasionally. 

The method by which this liquid nourishment is to be administered 
is of quite as great importance as is the quantity. It must be given 
in small amounts at short intervals, so as to prevent the patient filling 
his stomach by a large drink. A wineglassful every hour would repre- 
sent three pints in the twenty-four hours ; but, then, in ordinary cases, 
the patient should not be disturbed frequently during the night, and 
therefore double this amount may have to be given during the day and 
evening. The nurse must, therefore, be permitted to use her discretion 
according to the individual peculiarities or tastes of the patient, the 
main idea being adhered to, that, as far as possible, the total amount 
of nourishment should be as evenly as possible divided over the time. 
In the early morning the patient generally needs his food most, and in 
typhoid and typhus fevers, in their advanced stages, the life of the 
patient may be depending upon the conscientious discharge of the 
nurse's duty in this particular. 

The opposite extreme must be guarded against. There is nothing 
but injury can follow the administration of quantities of milk beyond 
the digestive powers of the patient, and the physician by inspecting the 
motions from time to time can gain valuable information upon this 
point. It is hard to hit off the requisite amount necessary, but upon 
the whole it will be better to err a little on the side of giving too much. 
The milk may be given warm, cold, or even iced, to suit any strong 
inclination on the part of the patient. It will be better to give it iced 
when possible. 

Soda, kali, or plain carbonated water may be mixed with it in vary- 
ing amounts according to the requirements of the case. It is cruel to 
refuse an occasional small draught of water or iced water when the 
patient craves for it, the only objection to this is when water or ice is 
allowed to take the place of nourishment in patients who have little 
appetite, as may often be seen in the case of children. One system of 
treating typhoid fever consists in the administration of large quantities 
of water with the view of promoting elimination. This should always 
be kept in mind. 



TYPHOID FEVER. 863 

The question of peptonizing the milk is one which must be con- 
sidered, and it is the opinion of the writer that it is not advisable to 
adopt this as a routine practice in every case. With patients possessing 
good digestive powers it is generally unnecessary, and sometimes turns 
them against the food. An inspection of the motions may settle the 
question. If much firm curd, or if in liquid motions the undigested flaky 
coagula are clearly visible, the diet must be altered. Either the patient 
is not being fed at proper intervals, or he is having more than it is 
possible for him to be expected to digest, or else his digestive powers 
are weakened, or else the irritability of the bowel is hurrying its con- 
tents too rapidly along the canal to permit of digestion and absorption. 

A little reflection will dictate the best course in such cases. Lime- 
water or kali water may effect the desired change by its action upon 
the milk. Sometimes a change to beef tea or cold chicken jelly may 
set matters right, or a little good arrowroot may be boiled with the 
milk, or a very pure isinglass may be added. 

If the patient's vital powers are low the milk may then be peptonized 
by using Fairchild's powders, or by adding a little liquor pancreaticus. 
In such a case the question of stimulants will have to come to the front, 
as will be presently discussed, and if these are indicated the requisite 
dose of brandy or whiskey may be mixed with the milk before admin- 
istration. This latter plan often succeeds better than any other, even 
in those cases where the patient occasionally vomits solid curds. 

In cases where milk cannot be taken in sufficient amount, the ques- 
tion of liquid animal food must be considered. Some physicians give 
beef tea and soups in all cases as a matter of routine. These certainly 
may be given in typhus always, but in many cases of typhoid fever 
they excite or increase diarrhoea, and may do harm. 

In many cases, and, indeed, in nearly all cases at some period of 
their progress in typhoid fever, beef tea strengthened by meat extracts 
and good soups carefully strained are highly advantageous. 

The equivalent of one pound of butcher's meat made into good beef 
tea may be safely given during the twenty-four hours alternately with 
the doses of milk in most cases from the very beginning, if care be 
taken to suspend its administration upon the onset of diarrhoea. Con- 
stipation is very often present throughout the attack, and it is then that 
the value of animal soups is most apparent. 

The routine dietary of the writer in hospital and private practice is 
to adhere to milk until constipation declares itself, and then either to 
suspend the milk entirely for a time, or to give an equal amount of 
beef tea or strained chicken soup alternately with it. At a later stage 
an occasional dose of a good mutton broth, carefully strained through 
a fine sieve and deprived of all fatty matters, will prove a substitute 
for castor oil or the enema. Raw beef j uice and barley and oatmeal 
gruels well strained are praised by Ziemssen. Calves'-foot jelly and 
gelatin blanc-mange are admissible, but only in cases where the patient 
is able to take a sufficient amount of milk or other valuable nourish- 



864 TYPHOID FEVER. 

merit. Rennet, with a little carefully prepared currant jelly or strained 
fruit juice, may be permitted. 

When any change from the pure milk diet is made the temperature 
chart is to be closely scanned, and it will be ofcen observed that the rise 
which sometimes follows can be attributed to the animal food. 

Starchy foods are not to be employed except under special circum- 
stances. They do not appear to be digested easily in typhoid fever, 
and diarrhoea has often been the result. The writer enters a protest 
against eggs, though their use is advocated by Murchison, Cayley, and 
others. He has seen them so frequently excite intestinal irritation and 
favor decomposition or fermentation in the alimentary canal that he 
has of late years given up their use as a food entirely in all stages of 
typhoid. In the convalescent period eggs seem to act in the opposite 
way, and to produce an obstinate constipation. Ziemssen thinks that 
three eggs^er diem are enough. 

After the subsidence of the fever the physician will be tempted to 
permit a change in the diet. In contemplating this it will be advisable 
to summon up the mental picture of the possible state of the ulcerated 
Peyer's patches and solitary glands. It will be advisable to refuse the 
patient's request for solid food until ten or twelve days after the normal 
temperature has been reached. 

Boiled white fish is, perhaps, the first solid meat which can be safely 
permitted, with tea or weak coffee, in which any plain biscuit may be 
soaked. Ord advises a return to solid food at an early date if the 
patient clamors for it. He states that he has learned to give in to this 
strongly stated desire upon the part of the patient for solid food. The 
writer has not yet learned to do so. 

Medicines are of very secondary importance in mild uncomplicated 
typhoid fever. As yet we do not know of any agent capable of cutting 
short the attack at any stage of its existence. 

Calomel in 10-grain doses was much used, and still is in some places 
on the Continent in the early stages, with the view of cutting short the 
disease. Liebermeister gave three or four such doses during the first 
twenty-four hours, and was satisfied that he caused the attack to abort 
in a number of cases. The older plan of giving emetics and drastics 
has been now fairly exploded. 

There seems every reason to hope that an agent will be discovered 
which will be found to cut short the disease. When such discovery is 
made, it will be probably found to be some well-known remedy used 
upon a new plan. 

Boric acid was tried by the writer as a routine treatment, and it 
promised very well ; but he eventually had to discontinue it in the 
doses which he hoped would prove useful, owing to its disturbing effect 
upon the stomach. 

Hydrochloric acid in 15 or 20 minim doses, diluted with 1 ounce of 
water, is the most popular, agreeable, and harmless drug which can be 
used in the routine treatment of this fever, typhus, or smallpox. It 



TYPHOID FEVER. 865 

acts as a febrifuge only by virtue of its effects upon the parched tongue, 
mouth, and throat, whereby it increases the salivary secretion, and in 
the stomach supplies an element probably very deficient in febrile con- 
ditions. Moreover, it forms an agreeable medium for the administra- 
tion of other drugs indicated in the various complications which may 
arise during the course of the disease. 

There is scarcely a known antiseptic agent which has not been tried 
in this disease, from corrosive sublimate or the biniodide down to the 
carbolic acid compounds, each in its turn earning a short-lived reputa- 
tion. It would profit little to take up our limited space with a rehearsal 
of the hopes and disappointments caused by the reports and trials of 
these so-called abortive specifics. 

Alpha-naphthol, naphthalin dioxide, naphthalin, betol or naphtholol, 
naphthol or beta- or iso-naphthol or hydronaphthol, and several 
other bodies of this series are still being tried. Dr. Mitchell Clarke 
brings considerable evidence to show that the best intestinal disinfect- 
ant is hydronaphthol, given in doses of 2 or 3 grains in the form of a 
pill coated with keratin, every two or three hours, or it may be given 
suspended in milk. Petteruti and others give larger doses —up to 60 
grains daily. 

Salol is* believed to produce intestinal asepsis when given in fair 
doses. 

The antipyretic treatment of typhoid fever is a large subject, and 
very contradictory views are held by different authorities. The agents 
employed in this method may be divided into two groups — viz., chemi- 
cal antipyretics and hydropathy. The former class will be discussed 
first. It contains a host of agents, and includes all the new and old 
drugs possessing the power of reducing fever heat, such as quinine, 
antipyrine, antifebrin, salicylates, phenacetin, carbolic acid, thallin, 
paracreasotinate, salpyrine, salol, kairin, digitalis, sulphocarbolates. 

Before referring to the relative values of any of these agents, it 
must be stated that there are still some who maintain that the fever 
heat is conservative, and, if checked, the patient is either injured or 
the attack prolonged. Though the writer has not seen much to en- 
courage him in the routine employment of antipyretic drugs in typhoid 
or other continuous fever, nevertheless he is perfectly satisfied that the 
principle of combating the fever heat is a perfectly sound one. It is 
only with the imperfections in our present agents that fault is to be 
found. As soon as a perfectly innocent antipyretic possessing slow but 
continuous action is discovered, then there may be safely predicted a 
great drop in the mortality of the continued fevers. Quinine has been 
long used for this purpose ; but for producing a definite and marked 
depression of fever temperature it is, perhaps, the least reliable of all 
our agents. It has, nevertheless, great advantages over its new rivals 
in some respects. Thus its powerfully tonic properties and its slow 
but more steady and continuous action, when carefully administered, 
make up for its deficiencies in other respects. 



866 TYPHOID FEVEK. 

In the writer's hands it has generally failed in satisfactorily reducing 
the fever heat when this has been very high — i. e., when approaching 
to 105°, except in the case of children. This experience may be par- 
tially accounted for by the fact that he has generally only resorted to 
it in bad cases, and then it very often fails entirely. Its best effects 
are to be obtained in conjunction with hydropathy. Less than 30 
grains will be of little use, and sometimes the dose may be repeated 
three or four times in the twenty-four hours without appreciably telling 
upon the temperature. 

At this point it may be well to remark that hyperpyrexia cannot be 
safely treated by any known antipyretic drug. 

There is a group of cases where- a moderately high and sustained 
temperature persists for many days, in which quinine often acts fairly 
well if given steadily at the rate of 5 grains three or four times a day, 
for about a week or more. Its good effects may be proved in these 
cases by suspending it, when the temperature will generally be found 
to rise again. There can be little doubt that it is beneficial if it be 
only capable of keeping down the heat steadily for one or two degrees. 
In the case of children a 5-grain dose often lowers the temperature 
three or four degrees. It is best given in wafer paper. Upon the 
whole, however, quinine, as a routine antipyretic remedy, is not very 
satisfactory, and where the temperature is very high it is useless. Occa- 
sionally it excites severe vomiting and distressing cinchonism. 

Digitalis is open to the same objections, and also labors under the 
great disadvantage of proving poisonous when given in large doses ; 
its proper place seems to be when given in combination with moder- 
ately large doses of quinine — 10 grains of quinine and 30 minims of 
the tincture. 

Antipyrine seldom or never fails to make a very decided impression 
upon the temperature. The same is also true of antifebrin. By these 
agents a drop of four or five degrees can be easily and constantly 
effected. Formerly 30 grains of antipyrine were given, followed by 
15 grains in one hour or half an hour, and 15 grains again inside 
another hour if the temperature had not fallen. By this plan it was 
not unusual to see a fall of eight or more degrees. Dangerous col- 
lapse has often followed these doses, which are now generally aban- 
doned ; 10 grains or even 5 grains of antipyrine, or 3 or 4 grains of 
antifebrin every four, five, or six hours, is the usual method of admin- 
istering these drugs, and in a few cases the physician may be able to 
satisfy himself that he can, by this plan, keep the temperature within 
bounds. He will, however, far more frequently find that after the 
drop there will be a marked tendency toward a greater rise, and after 
altering the doses and changing the length of the intervals, he soon 
begins to find that the depression and profuse sweating, and other 
untoward effects, produce greater mischief than any good obtained by 
their antipyretic action. 

A very important result, of which the writer has satisfied himself 



TYPHOID FEVER. . 867 

repeatedly, is the unevenness of the effects of these agents in the same 
patient during different days of his illness. Thus, a severe typhoid 
case which bore 20 grains of antipyrine well for several days was 
almost snuffed out by a 5-grain dose given at a later stage. He has 
also seen one case in which a single grain of antifebrin would keep the 
temperature depressed for twenty-four or thirty- six hours, though this 
patient at first bore moderate doses well. 

Where, owing to some passing complication the temperature rises so 
high as to threaten exhaustion during the middle of a typhoid attack, 
these agents are of the greatest value in reducing the fever heat and 
assisting the patient through the additional danger, but in keeping 
steadily down the temperature for any length of time in a severe con- 
tinuous high fever, their action is open to doubt. Antifebrin appears 
to exert a more continuous effect, but the cyanosis and other symptoms 
which have been so often of late observed are making physicians 
hesitate to employ it except in small doses. 

Phenacetin, salicylates, and the other newer antipyretics do not 
appear to give any more promising results, but though their action in 
cutting short the attack is yet to be proved, and their failure in keep- 
ing the temperature uniformly reduced is recognized, it cannot be 
questioned that the employment, when carried out judiciously, of the 
different members of this class of agents may greatly aid the patient 
in his struggle against the disease. His general distress may be much 
relieved, any pain present will be soothed, and sleeplessness may dis- 
appear along with headaches and anxiety by their occasional exhibition. 

Hydropathy in the routine treatment of typhoid fever has excited 
great attention of late years. The effects of the cold or tepid bath in 
reducing the fever heat with certainty, safety, and precision is becom- 
ing more and more clearly recognized. In very severe cases or in 
hyperpyrexia there is really no other method of treatment available, 
as the agents just mentioned are not to be relied upon. About this 
there cannot be any difference of opinion ; but when we come to con- 
sider the advisability of employing the cooling bath as a routine 
agent in all cases of the disease, serious differences of opinion still 
exist ; but it may be truthfully said that under clearer knowledge and 
more improved methods of administering this agent, and a steadily 
diminishing rate of mortality, these differences are more or less rapidly 
disappearing. There are, therefore, many reasons to tempt one to 
believe that the routine administration of cold or tepid water as an 
antipyretic will soon become as generally practised as is the rest and 
liquid diet treatments, except in the very mildest of cases. 

The plan first carried out by Brand is still adhered to in bad cases, 
but for routine use it is variously modified. He places the patient 
four to eight times a day, after a small dose of stimulant, in a bath of 
water at a temperature of about 68° F., for fifteen or twenty-five 
minutes until he feels chilled and begins to shiver. His limit of temper- 
ature is 102.2° F. in the rectum. As soon as the thermometer 



868 - TYPHOID FEVER. 

reaches this height the bath is ordered. When the mercury registers 
a drop of 2£ degrees he is to be taken out of the bath, wiped dry, and 
put to bed. Very mild cases will not come under this rule, as the 
temperature may never reach 102.2°. Liebermeister recommends the 
routine use of the bath only when a temperature of 103° is reached. 

The mortality under Brand's treatment has fallen from 15 or 20 per 
cent, to 3.9 per cent. Taking all the different reports from favorable 
and unfavorable reporters, one is safe in saying that the routine em- 
ployment of the cold bath has diminished the mortality by at least 50 
per cent. 

There are many modifications of Brand's method, and some of these 
are improvements. It is demonstrated that a cold bath is unnecessary, 
and many have obtained excellent results with water at a temperature 
from 90° to 95° F. The higher the temperature of the patient the 
lower should be that of the bath. 

Ziemssen highly praises the bath at about 90° F. He advises that 
the water in it should be constantly stirred, and that the patient's 
body be wholly immersed in it. It should be gradually cooled down 
to 80° F. by pouring in cold water at the patient's feet. The duration 
of the immersion should be over fifteen, but not exceeding thirty 
minutes. By this plan, which has been much practised, the prejudice 
against the dangers of cold water is removed and the sensations of the 
patient are much more pleasant. Shock is avoided. 

Always, however, in hyperpyrexia a temperature of about 68° or 
70° should be employed, but the very cold or ice bath should be con- 
demned. Ziemssen uses a warm bath in adynamic cases. 

Under the cool bath the heart beats more vigorously and slowly, 
and the pulse improves in tension, while appetite and digestion are 
greatly assisted, but it does not seem that there is any proof that the 
ulcerative process is altered in the intestinal regions. 

An us chat strongly advises warm baths instead of cold. He insists 
that it is the water, and not its temperature, which is the most impor- 
tant factor. His baths vary from 95° to 90°, under which last figure 
he does not go, even if the temperature reaches 105°. He claims that 
decided improvement sets in in three or four days of treatment. There 
is almost entire absence of secondary symptoms, and a much shorter 
duration of illness, 145 out of 150 patients being less than four weeks 
and many less than three weeks in bed. 

Upon the other hand, some physicians insist upon the value of cold 
affusions very frequently repeated. The writer has resorted to this 
method when a bath was not available, the patient being enveloped in 
a thin sheet and cold water poured freely over him. 

Barr has employed a tank about 6x3x1 feet, lined with lead 
and filled with water varying from 90° to 98°. In this he keeps the 
patient for a period of one to four or more weeks. A blanket is 
wrapped round the body, and a pillow to keep the head above water, 
and a half lid to the tank constitute the machinery for carrying out 



TYPHOID FEVER. ■ 869 

this treatment. There is the great difficulty of the bowels, which he 
permits to be relieved in the bath, the water being made antiseptic. 
Success has hitherto been the result of this " not very aesthetic" method 
of treatment. 

Simple spongiug of the body in detachments has been resorted to 
by those who believe in the antipyretic treatment, but who are afraid 
to insist upon the cold bath. The wet pack is even better, and there 
is no doubt that systematic sponging patiently with cold or tepid water 
will bring down and keep down the temperature considerably. 

The writer's great difficulty in the use of the cold or tepid bath is 
the movement of the body which it entails. A simple appliance is yet 
to be devised to obviate this. Every three hours, if the temperature 
shows a rise up to 102.2° (Brand), or to 103° (Liebermeister), will not 
be too often for a fifteen-minute immersion through the day and night. 
Severe hemorrhage and great tympanites or peritonitis, with serious 
cardiac depression, are the only contra-indications to the use of the 
bath. The writer thinks that coldness of the extremities should be a 
contra-indication even when no other sign of cardiac failure is present. 
Renal complications appear to do well under the baths. 

Alcohol. The question of giving stimulants in typhoid and other 
fevers has been already referred to. There are certain general princi- 
ples which will meet with almost universal acceptance, while some 
disputed points will be considered later on. The majority of cases do 
not require any stimulants at any stage of their progress. The routine 
practice of administering stimulants in fevers is growing gradually less 
and less. Seldom, if ever, are they indicated in the early stages of the 
disease unless in the case of those addicted to their habitual or daily 
consumption. A patient who appears to have the indications for 
alcohol during the first week of his attack will, in all probability, be 
beyond the influence of remedial agents. The writer does not hesitate 
to give alcohol when indicated in the way to be presently mentioned, 
and when he gives it, it is with no sparing hand, but he is decidedly 
opposed to it as a routine treatment. Statistics, if impartially consid- 
ered, would seem to prove that the routine use of alcohol and the rigid 
exclusion of alcohol all round will bring the mortality to about the 
same thing. This is his belief, and it may be put in two ways — either 
that alcohol is useless or unnecessary, or that it is at least not injurious, 
since if it does not lower it does not raise the rate of mortality. 

There is, however, another way in which to look at the unanimity 
of the two classes of statistics which may be nearer the truth, and it is 
this : Those who stoutly refuse to administer alcohol in all cases will 
probably lose some lives by withholding it, and those who give alcohol 
in every case will probably sacrifice some lives by its use. The number 
influenced will probably be a very small percentage of the whole. 

Every case must, therefore, be weighed upon its merits, and a 
decision should only be arrived at after weighing the indications for 
and against, just in the same way as if opium, or calomel, or antipyrine 



870 ' TYPHOID FEVER. 

were being discussed for administration to meet certain clear indica- 
tions. The debatable question of giving alcohol as a food need hardly 
be discussed here, though there can scarcely be a doubt that a consider- 
able portion of it is burned or used up in the body just as other foods 
are. A small percentage of cases may be improved, and the patient's 
chances of recovery increased by giving small doses of alcohol along 
with the milk food where there is good reason to believe that the 
digestive powers are weak, and where close observation proves in the 
case before the physician that the addition of a teaspoonful of good 
whiskey or brandy actually does assist the digestion of other nourish- 
ment when given along with each dose of it or immediately afterward. 
There are various indications which are relied upon, as calling for 
alcohol in severe cases. These are mainly symptoms of cardiac failure, 
and those who place their faith in alcohol in such cases, do so because, 
among other actions which, it possesses, they believe alcohol to be the 
best cardiac stimulant. 

A weak, unsteady, and easily compressed pulse, and a corresponding 
condition of the heart, with the typical symptoms of the " typhoid " 
state, are regarded as clear evidences of the necessity for alcohol. 
The writer has watched by the bedside the effects of alcohol under 
these circumstances, and he has satisfied himself that by its use life 
may sometimes be saved, which, without it, would be lost. The effect 
of the drug requires the closest watching, and herein lies the secret of 
success, because it may sometimes be found to do harm in the case 
where the indications for its use may appear clear, and it is the duty 
of the physician to give the case his anxious attention for the first 
six or twelve hours after beginning the alcoholic treatment. 

Brunton in his clear and forcible style puts the case so : 

"The various rules which have been given for the administration of 
alcohol in fevers may be condensed into one. If the alcohol tends to 
bring the patient nearer to his normal condition, it is doing good ; if it 
takes him further away from the healthy condition, it is doing harm. 
The points which are usually specially attended to are the condition of 
the tongue, pulse, respiration, skin, and nervous system. 

" If it is found that the alcohol (a) renders the dry tongue moist, 
(6) slows and strengthens the pulse when it is too quick, or quickens it 
when it has become abnormally slow, (c) slows the hurried respira- 
tion, (d) renders the skin cooler or moister when too hot and dry, and 
(e) lessens delirium and brings on sleep — then its action is beneficial. 
If it have an opposite effect it does harm. Useful indications regard- 
ing the advantage of alcohol and the dose may be obtained by the 
practitioner remaining beside the patient counting the pulse and watch- 
ing the tongue, respiration, skin, and general condition of the patient 
for a quarter of an hour after the dose has been given. Particular 
care should be taken in the administration of alcohol to patients in the 
small hours of the morning. It is about this time that attendants are 
most apt to become sleepy, and therefore careless, and just at this time, 



TYPHOID FEVER. 871 

also, the external temperature is lowest, the fire is apt to get low, and 
the vital powers of the patient are most likely to sink." 

The question of the dose and form in which the alcoholic stimulant 
is to be given is an important one. First, as regards the variety of 
alcohol, the writer believes that brandy or whiskey should always be 
preferred to wine, and the selection of brandy as against whiskey, or 
vice versa, should be made after considering which of these agents can 
be procured in the purest form. As a rule, in this country, a pure 
whiskey is more easily obtainable than a pure brandy, hence, the 
writer always employs whiskey, and he is satisfied that the product of 
the patent still should not be employed. The so-called " silent " spirit, 
and the numerous blends into which it enters, do not produce the car- 
diac stimulating effects of a matured malt whiskey produced by the 
old pot-still process. The ethers produced by the splitting up of the 
traces of fusel oil left in the latter process possess valuable stimulating 
properties, and, moreover, they appear to aid in the entire combustion 
of the spirit in the blood. The whiskey can be given to the greatest 
advantage along with the milk, when the patient does not object to 
this plan. 

As regards the dose, the symptoms and their severity, and the ascer- 
tained effects of the agent, must be taken into account along with the 
previous history of the patient. 

The practice of the writer is only to give alcohol when clearly and 
urgently needed. Hence the dose which he generally employs will 
appear larger than that usually recommended. Two or three ounces 
in the twenty-four hours, as often mentioned by writers, can be of no 
use in severe cases, and in mild cases the patient will probably be as 
well or better without them. The only value that can come of such a 
small quantity is that already mentioned, i. e., to aid in the digestion 
of the liquid nourishment. 

Less than 5 ounces of old whiskey spread evenly over the twenty- 
four hours will be of little use to an adult in the condition indicating 
the exhibition of alcohol. In bad examples of the typhoid state, with 
a very fluttering pulse, dry tongue, and mouth covered with sordes, 
the writer has given twice and sometimes three times this quantity 
with the greatest benefit. 

Wood states " that, properly administered, it always promotes, not 
arrests, secretion in these cases. The guide to the amount given 
should be the effects produced ; so long as it lowers the temperature 
and pulse rate, moistens the dry tongue and skin, and quiets the nerv- 
ous disturbance, it does good. If, however, the tongue grows drier, 
the pulse puts on an angry, bounding character, and the patient be- 
comes restless and uneasy, stimulation is being pushed too far, and the 
amount exhibited should be lessened. Whenever the odor of liquor 
appears upon the breath the patient is almost certainly taking too 
mueh" 

Large doses of alcohol have a lowering effect upon the temperature 



872 TYPHOID FEVER. 

but it is out of the question to think of using it merely for this pur- 
pose in typhoid fever. Where the cold or tepid water bath is beiug 
used, a small amount of alcohol is considered necessary, and there is 
no reason why alcohol, quinine, and the tepid bath may not be all in- 
dicated in the same case. 

Where complications exist, the choice of the form of alcohol may 
be determined by the nature of the symptoms present. Thus, where 
stimulants are indicated and the patient is vomiting, champagne may 
be selected instead of either brandy or whiskey, and if diarrhoea is a 
marked feature, the effects of a good old port wine may be tried. 

Where the stimulant cannot be given mixed with the food, it should 
be administered in a very diluted form. 

The writer, in the last edition of his work on Materia Medica and 
Therapeutics, thus sums up the alcohol question in fevers : Most 
authorities, however, would probably agree (1) that alcohol is not 
necessary at all in the majority of cases ; (2) that often unpromising 
cases pull through without it ; (3) that in severe cases it cannot be 
safely withheld from those habituated to it ; (4) that occasionally by 
the use of alcohol life may be saved which would otherwise be lost ; 
and (5) that it is rarely needed in the very large doses prescribed by 
some — 6 to 10 ounces of whiskey may be regarded as representing a 
liberal daily allowance. 

Such, then, will be the routine treatment of typhoid fever, but com- 
plications must be met. They are the rule, a case without them being 
the exception. The management of the complications will now be 
briefly detailed. 

Sleeplessness. This may prove a troublesome symptom in the 
disease from the earliest stage, and any of the usual hypnotics men- 
tioned under Insomnia may be employed. The writer prefers a draught 
like the following : 

R . — Morphinse hydrochlor gr. ss. 

Sodii bromidi gr. xlv. 

Syr. aurantii * . ^iij. 

Aquse camphorse ad ^ij. — M. 

S. — The half to be taken at bedtime, and the remainder in three hours if 
necessary. 

Where the sleeplessness depends upon headache, this should be re- 
lieved, if possible, first, and in such a case morphine or opium may 
aggravate it (see below). Chloral is a favorite drug with some physi- 
cians, The writer never uses it unless all others fail, and this is very 
seldom. In the late stages of this disease, or even more so of typhus, 
it is a dangerous agent, owing to the fatty degeneration of the heart 
which for a time follows all prolonged high temperatures. 

Sulphonal acts very well, but it should be given in solution. It can 



TYPHOID FEVEE. 873 

be easily dissolved in a large quantity of boiling water, and given 
when partially cold with a little stimulant. 

The watery extract of opium or the tincture may be selected where 
we have a relaxed condition of the bowel as well as insomnia. 

Headache. This is sometimes violent in bad cases at the begin- 
ning, and the following measures are those used by the writer : A 
mustard plaster behind the upper part of the neck and over the occi- 
put, extending upon the sides as far as the back of the ears. A mod- 
erate dose (15 grains) of antipyrine repeated in one or two hours. If 
relief be not marked, clipping or shaving of the hair, and the ice-cap, 
or Leiter's tubes, and in very bad cases leeches may be applied to the 
temples. This will seldom be necessary, except in those rare cases 
beginning like acute mania. 

The cold pack or bath, or tepid bath, if the temperature be very 
high, generally gives speedy relief. Quinine often aggravates. 

Delirium will, as a rule, yield to the same remedies as the head- 
ache in the early stages of the disease. Absolute quiet and darkness 
will aid the above-mentioned drugs. At a later stage the cause of the 
delirium must be sought for and remedied, when possible. Thus, it 
may be the first sign of a pneumonia, meningitis, or even an intestinal 
hemorrhage or renal complication. The writer has seen it yield to the 
emptying of an enormously distended bladder which had been over- 
looked. Coma is to be similarly dealt with. The treatment of the 
typical typhoid state has already been referred to, the main agent being 
large doses of alcohol. In one case, where the delirium and coma of 
typhoid fever rendered the patient's condition hopeless, the writer saved 
life by pouring in large quantities (1 ounce every hour) of whiskey 
through the tube of a feeding-cup placed far back upon the root of the 
tongue, the power of swallowing being almost lost. 

Musk in 3 grain doses may be given in such cases, and if the tem- 
perature is high, the cold bath after a hypodermic injection of ether 
or a rectal dose of alcohol should be tried. Cold affusion sometimes is 
very valuable in such cases if applied when the patient is lying in the 
tepid bath. 

Diarrhcea should not be interfered with unless the number of 
motions exceed four in the day, and not then if they be not large in 
amount and very watery. A careful inspection of the motions should 
be made in such cases, and, by a change in the feeding, the bowel irri- 
tation may be stopped. Undigested curd of milk or too much beef tea 
or soup may be the cause. The writer has seen the dilute hydrochloric 
acid mixture, as ordinarily given, produce diarrhoea. Peptonizing of 
the milk, or the addition of whiskey or brandy, and the withdrawal of 
all meat extracts and starchy foods, may at once check it. Arrowroot 
boiled in milk, and made very thin, so as to be taken as a drink, may 
be tried before drugs. It is the only starchy food admissible. 

Opium, to relieve the exalted peristalsis of the bowel, is the most 
reliable drug. With it may be combined some agent to effect intestinal 

56 



874 TYPHOID FEVER. 

antisepsis. Though the writer has never tried naphthol, he is prepared 
to believe that when some method is discovered by which it can be 
given without upsetting the digestion, an advance in the therapeutics 
of typhoid fever will be recorded. 

The best form for the administration of opium is an enema of starch, 
of creamy consistence, not exceeding the capacity of a wineglassful, 
along with 30 minims of laudanum. 

Where there is irritability of the rectum, 20 minims of laudanum 
may be given every three hours or oftener by the mouth, and where 
vomiting occurs, the y 1 ^ grain of morphine perule may be given. 

The following is a favorite hospital routine mixture for the diarrhoea 
of typhoid: 

K- — Acid, sulphuric, aromat. 3j. 

Tinct. opii ^ijss. 

Tinct. catechu comp giv. 

Aquae camphorse ad ^ x. — M. 

S. — Two tablespoonfuls to be taken three times a day or after every loose 
motion. 

In very obstinate diarrhoea, lead may be given combined with the 
opium, 2 or 3 grains of the acetate and 10 minims of laudanum after 
every loose motion. Tannin, logwood, chalk mixture, rhatany, etc., 
and the host of astringents mentioned under Diarrhoea, upon page 
190, have been given. Opium is by far the most reliable of them all. 

Hot enemata are highly recommended by Geissler, who gives 20 
ounces of water at a temperature of 108.5°, and reports that the num- 
ber of stools are lessened and rendered less mucoid. Teissier, of 
Lyons, employs a cold enema every six hours. Other authorities go 
in for washing out the colon with various antiseptic solutions, but this 
is a practice not to be commended with our present knowledge. 

Constipation is often as troublesome as diarrhoea. After trying 
every method, the writer finds that where beef-tea and meat-soup diet 
is not sufficient to keep the bowels right, a glycerin suppository is very 
satisfactory. It can be given without any difficulty, and generally acts 
in a short time. Where it fails, a warm water enema may be given, 
and repeated as often as is necessary. 

Drastics and all cathartics are strictly forbidden. The only aperient 
which is safe is castor oil, and the dose of this should not exceed 2 
drachms at the outside. It should not be given, if the constipation has 
lasted many days, until the rectum is washed out by a large olive oil 
and warm water enema. Eggs are not to be administered, as they tend 
to increase the constipation. 

Hemorrhage is a very formidable complication, and there is not 
any drug so valuable as opium. In severe cases 40 minims of lauda- 
num may be given by the mouth, and if there be any vomiting pres- 
ent, a hypodermic injection of morphine should be given without 



TYPHOID FEVER. 875 

delay. The nurse should manage to give as little disturbance to the 
patient as possible in the use of the bed-pan ; in some cases life may 
depend upon such absolute rest that even this appendage must be dis- 
pensed with, napkins and other appliances being used for the time. 
Cold to the abdomen should be tried. The large ice-bag is too heavy. 
A napkin laid in two folds over the abdomen with small pieces of ice 
between answers all purposes. 

In severe cases food by the mouth is to be almost stopped, life being 
sustained by minute doses of concentrated beef essences, given at con- 
siderable intervals, with small pieces of ice between, and the regular 
administration of small peptonized enemata of strong beef tea, to each 
of which a few minims of laudanum may be added. Iced enemata are 
recommended, but they do more harm than good in some cases. 

Where opium and the above measures fail, the haemostatic class of 
drugs may be tried. Dr. J. S. Eeid, whose experience of this disease 
is very great, places his reliance upon alum in full doses, given by the 
mouth. Ergot, lead, tannin, chloride of iron, iron alum, logwood, sul- 
phuric acid, turpentine, and every known astringent has been tried. 
(See the relative values of these discussed under Haemoptysis, Hemor- 
rhage, etc. 

Stimulants should be partly suspended, only enough being given of 
food and alcohol as will keep the patient alive until in the period of 
dead low water the open vessel has been sealed up by a coagulum. 

Perforation can only be met by the most rigid rest and large 
doses of opium, so as to border upon slight coma, cold to the abdomen, 
and the maintenance of life by small peptonized enemata, and a very 
few bits of ice sucked in the mouth. If good nutrient suppositories 
are at hand they would be indicated. There must be no movement of 
the patient's body made in administering the enemata. His faint 
chance for life depends upon starvation, rest, and opium. This latter 
is to be given by the rectum or hypodermically. 

Peritonitis is to be treated upon the same lines — rest and opium. 
Cold applications are, as a rule, not so well borne as warm ones, and 
the best plan is spongio-piline soaked in hot water and kept in place 
by a light bandage. Poultices are generally, unless very skilfully 
made, too weighty. 

Bedsores should be prevented by careful nursing. When they 
have occurred they must be treated by absolute cleanliness and the 
applications detailed under Bedsores, page 65. 

Retention of urine can only be met by catheterization, and the 
soft rubber catheter should always be employed. Where the urine is 
ammoniacal the bladder may be washed out by some antiseptic solu- 
tion, or, better still, by adding 20 grains of boric acid to the day's 
supply of milk. 

Miscarriage, pneumonia, albuminuria, and other complications are 
to be treated upon general principles, keeping in mind the indications 
for the various drugs mentioned under the heading of the complication. 



876 TYPHUS FEVER. 

During convalescence the greatest care is to be exercised regarding 
diet and locomotion. Every time solid or animal food is administered, 
for the first few days the range of temperature is to be carefully 
watched and a return to liquid food insisted upon if any substantial 
rise occurs. It is almost a universal mistake to prolong the adminis- 
tration of alcoholic stimulants too far into the convalescent period. 
The patient should not be permitted to leave his bed for twelve or 
fourteen days after the temperature has fallen to the normal. Some 
physicians begin drugging with tonics, but these are seldom necessary. 
The writer feels that the following summary of the treatment of 
typhoid fever is well worth repeating; it is from an* able address 
delivered by Bristowe in 1880 : 

" In conclusion, gentlemen, let me state briefly the treatment to 
which I should like to be subjected if ever, unfortunately, I should 
become affected with enteric fever. I should like to be placed in a 
cool, well-ventilated room and covered lightly with bedclothes, and to 
have a skilful and attentive nurse to look after me ; to be fed solely 
with cold milk, unless vomiting should demand the addition to the 
milk of medicine calculated to allay vomiting. If diarrhoea became 
troublesome, or ever there was much pain or tenderness in the csecal 
rings and in the bowels, I should like to be treated not with laxatives, 
but with opium, given ether by the mouth or by the rectum. If con- 
stipation were present I should, excepting in the first week, like to have 
enemata only employed for its relief. In the event of intestinal hemor- 
rhage coming on, I should like to have ice to suck, or ice-cold fluids to 
drink, cold compresses to the belly, and cold injections into the bowels ; 
and, though I am sceptical as to their efficacy, I should still chose to 
have astringents, and more especially lead, given to me at short inter- 
vals. If perforation should take place, let me have large and repeated 
doses of opium. Stimulants I should prefer to do without early in the 
disease; later, however, and during convalescence, I should like to 
have them in moderation. As to the cold baths, I would rather not 
have them, but I would nevertheless leave it to my physician to exer- 
cise his discretion in the matter. I would leave it also for him to 
decide, according to circumstances, whether alcohol should be admin- 
istered to me in large quantities. I would prefer not to be treated at 
a temperance hospital." 

TYPHUS FEVER. 

The previous article upon the treatment of typhoid fever, in most of 
its details applies to the treatment of typhus. 

The chief omission required will be the management of the compli- 
cations, which of course do not happen in typhus. 

The selection of the sick-room is detailed upon page 860, and the 
general directions regarding nursing, etc., are identical. This fever 
being highly contagious, the sick-room must be most completely cut 



TYPHUS FEVER. 877 

oft' from the rest of the house ; and it is held that, owing to the sup- 
posed nature of the contagion, the room should be at the top of the 
house or that no occupied rooms should be situated above it. 

Where there are many inmates in the house and where the air- 
space is limited, the wisdom of treating a disease which spreads 
alarmingly in over-crowded situations is more than doubtful. In the 
case of schools and public institutions it should not be attempted, 
removal being considered essential. 

It is almost as important as in typhoid fever to insist that the 
patient takes to bed immediately. 

Food is to be the same as in the case of typhoid. Though there are 
not the same urgent necessities for a purely liquid nourishment, owing 
to the absence of bowel ulceration, nevertheless the great advantages 
of a purely liquid dietary are so well recognized that every detail 
applying to typhoid fever in this respect holds here equally well. 
More beef tea and chicken or other soup can be given, as there is not 
the same danger of exciting diarrhoea, and it is a good plan to give 
milk and beef tea alternately in most cases where the patient takes to 
this method. 

The question of alcohol as discussed under typhoid exactly applies 
here. The stimulants may, however, be commenced at an earlier 
date; and speaking generally the writer would say that, in his expe- 
rience, there is more need of alcohol and more good to be expected 
from it in typhus than in typhoid fever. All old patients require 
it, but children very seldom do. Some epidemics of typhus are 
characterized by such depression that alcohol may be indicated in 
nearly every case. The dose may reach 15 or even 20 ounces of 
whiskey in the twenty-four hours. The key-note to the use of 
alcohol, antipyretics, and baths lies in this one consideration — that 
the siege, though a severe one, will be almost certain to last only 
fourteen days, and the entire effort and one thought of the physician 
should be, not to fight the disease with the view of exterminating it, 
but to try by a purely expectant method to keep the patient alive 
until the expiration of that time. In some cases within sight of the 
goal, life may be sustained upon stimulants when all else fails, but it 
must ever be remembered that life can be sustained upon stimulants 
for a very short time only. 

The remarks about antipyretics apply equally to typhus and 
typhoid, with this difference, that, as we know how long the attack 
is to last, we can the better judge of the necessity for their admin- 
istration. 

Chemical antipyretics have not yet been proved to be of any real 
service, and the value of the cold or tepid bath is not yet established 
in the same way as in typhoid as a routine element in the treatment. 
The occasional use of the bath is beyond doubt of the greatest value 
when the temperature is high ; but the writer thinks that its routine 
employment should not be commenced until the temperature reaches 



878 TYPHUS FEVEK. 

at least 103° Quinine may be used at the same time in some cases 
with advantage. The bath is the only reliable agent for hyperpyrexia 
in this as in other diseases. As in typhoid, the internal administration 
of 15 or 20 minim doses of the dilute muriatic acid is the best simple 
routine procedure. 

Delirium, headache, and sleeplessness may be met by ice to the 
head and counter-irritation to the nape of the neck. Some authori- 
ties blister the forehead or scalp in such cases. As a hypnotic, 
chloral may be used in conjunction with large doses of bromides ; 
but at a late stage it should not be given on account of the weak 
heart which is often an element of typhus. Opium cannot be borne 
when the headache and delirium are marked, unless when given, as 
advised by Graves, along with moderate doses of tartar emetic. 

The new hypnotics may be tried with advantage. Cold sponging is 
admissible in all cases. 

Coma must be promptly met by cold affusion, if the temperature is 
high, or by rectal injections of strong coffee or by coffee by the mouth, 
if the stupor is not complete. Murchison laid stress upon the neces- 
sity for counter-irritation over the loins with cupping-glasses or sina- 
pisms covered by mackintosh, in deep stupor, and he blistered the 
scalp by strong ammonia in some cases. The writer would recom- 
mend the hot blanket bath under such circumstances, and the general 
treatment for acute uraemia mentioned upon page 73, if albumin is 
found in the urine and the temperature be not high. 

Owing to the blurred mental condition of the patient his bladder 
must be carefully watched, and the soft rubber catheter passed as often 
as needed. Food must be, for the same reason, regularly forced upon 
him, and his position changed from time to time as he lies in bed, to 
avoid hypostatic congestion. 

Pneumonia must be met by free stimulation, counter-irritation, and 
the internal administration of ammonia in full doses. If the typhoid 
state be present, ammonia should not be given ; then full doses of turpen- 
tine, with a little ether and cajuput, are admissible. The glycerin of 
borax (1 : 5) should be applied to the tongue and mouth frequently, 
and bits of ice and small but frequent draughts of iced water may be 
given all through the disease. 

The patient often fails to ask for water, but the nurse should see 
that he gets it as regularly as his nourishment and stimulants. Free 
elimination is of vital moment, and water is too often withheld. 

After the fall in the temperature rapid convalescence begins. The 
stimulants should be lessened after the first twenty-four or thirty-six 
hours, and in three or four days almost stopped. By that time the 
appetite has improved, and semi-solids, as farinaceous foods, fish, 
chicken, oysters, etc., may be given inside a week from the fall in the 
fever heat. The following tonic is useful at this stage : 



ULCER. 879 

R. — Quininoe sulph ^ss. 

Acid, nitrohydrochlor. dil 3iv. 

Tinct. calumbcB \ _ . 
Tinct. quassise > 

Inf. aurantii ad ^viij. — M. 

S. — A tablespoonful in a wineglassful of water three times a day, before 
meals. 

ULCER. 

Under Gastric Ulcer, page 273, the treatment of ulceration of the 
stomach is detailed. 

Under Anus, page 46, the treatment of ulcer of the anus or rectum 
will be found. 

Rodent Ulcer, page 763, will give the remedial procedures for that 
affection. 

The treatment of ulcers of the mouth are described under Stomatitis 
and Tongue, on pages 785, 51, and 843. 

Lupoid, scrofulous, and syphilitic ulcerations are detailed under their 
appropriate headings. 

Perforating Ulcer of the Foot is mentioned under its own heading, 
upon page 597. 

The treatment of the various ulcers almost necessitates a description 
of each, so many varieties have been named, and the same words are 
used in different senses by different writers. The writer will describe 
the treatment of the healthy, healing, or simple cutaneous sore, which, 
in the vast majority of cases, is found upon the lower half or two-thirds 
of the leg in adults. At different stages of its progress such a sore may 
vary considerably in character, and by changes in the patient's health, 
or by injuries, or by prolonged exercise, etc., the healing ulcer may 
become an "inflamed," "irritable," "weak," "sloughing," "indolent," 
or " eczematous " sore. 

The treatment of the healthy or simple cutaneous sore or ulcer is, for 
the most part, easy. Rest and" the application of almost any moist 
dressing will speedily assist healing. 

Rest is the main element in treatment, but it is not easily obtained 
in most cases. Few people will take to bed for the sake of healing a 
small sore which is giving little trouble. Almost all the advantages 
of a prolonged rest in bed may be obtained through the application of 
an even elastic pressure. The introduction of the Martin's India-rubber 
bandage has wrought a revolution in the treatment of ulcers, and 
though its application is not essential for the healing of a simple 
ulcer, nevertheless in most cases it will greatly expedite it. Should 
the ulcer become chronic, its use is essential. There is a serious 
objection to the rubber bandage which maintains in many cases, and 
it is the liability of the retained secretion of the skin setting up a 
general eczematous condition of the entire limb. This may become 



880 ULCER. 

a serious matter. Hence the writer uses a modification of the bandage 
for most cases of ulcer of the legs, which he treats in the following 
routine manner: 

A double ply of lint is neatly cut out with scissors to the shape and 
size of the ulcerated surface. A piece of oiled silk, half an inch 
larger every way, also is prepared. The lint is soaked in ordinary 
carbolic lotion (1 : 40), laid upon the sore, and covered over with 
the oiled silk. Where there is any tendency to eczema, the skin 
around the edges of the ulcer, where in contact with the oiled silk, 
may be smeared over with a little lard, vaseline, or any stiff emollient 
ointment. This prevents irritation by the retained secretion under the 
oiled silk. Over the lint and oiled silk a woven rubber bandage, about 
three and a half inches wide (such a bandage as is used for Esmarch's 
bloodless operation), is applied evenly from the toes up. This bandage 
is manufactured in the same way as the elastic spring-sides of ordinary 
boots, and it is known as " elastic webbing." It should be taken off 
when the patient retires to bed, and put on before he gets up in the 
morning, any ordinary bandage being used to keep the dressing in its 
place during the night. 

Instead of the carbolic lotion, any of the following lotions may be 
used from time to time, according to the appearance presented by the 
sore — i.e., cold water, spirit lotion (1:4), chlorate of potassium (4 
grains to 1 ounce), chloride of zinc (2 grains to 1 ounce), liquor plumbi 
(15 minims to 1 ounce), black wash, yellow wash, corrosive sublimate 
(i grain to 1 ounce), chloral hydrate (3 grains to 1 ounce), acid, nitric, 
dil. (5 minims to 1 ounce), tincture of benzoin, hazeline, iodine (1 grain 
to 10 ounces), sulphate or nitrate of copper (1 grain to 1 ounce), nitrate 
of silver (5 grains to 1 ounce), boric acid (10-20 grains to 1 ounce), etc. 

Where any watery solution seems to irritate, an oily solution like 
carbolic oil (1 : 15), or almost any of the above-named substances 
made into an ointment with lard, spermaceti, or zinc ointments, or any 
of the following U. S. P. ointments : Diachylon, iodoform, lead car- 
bonate, carbolic acid, or oleate of zinc may be employed. 

When a greasy application is made "it is better, as a rule, not to cover 
it in with oiled silk, though the carbolic oil does admirably when so 
applied. 

The dressing may be applied twice daily, and if a liquid application 
has been used, a stream of tepid water should be passed over the face 
of the ulcer to wash away all secretion before the fresh lint is applied. 
When ointments or oils are used, the ulcer should be lightly cleansed 
by gentle wiping with cotton. 

Simple ulcers often heal rapidly by placing a piece of sheet-lead or 
thick lead-foil over the dressing. The writer has seen excellent results 
from the lead being laid directly upon the sore without the interven- 
tion of any dressing. 

Weak ulcers are those in which there are abundant flabby, pale, or 
watery-looking granulations. This condition may to a certain extent 



ULCER. 881 

supervene upon the healing ulcer, but it more frequently exists from 
the first, and is a strong indication for cod-liver oil and iron, pure air, 
and extra feeding. The local treatment may be summed up in a 
word — stimulation. The best of all remedies is the solid stick of nitrate 
of silver pencilled over the cedematous granulations, followed by a 
dressing of dry lint under a suitable elastic bandage. 

At a later stage the sore may be rubbed over every two or three days 
with a large crystal of sulphate of copper. The best dressing is the 
diluted nitric acid lotion or a weak solution of sulphate of copper or of 
nitrate of silver. 

To apply a piece of lint upon the sore which has been saturated in 
the tinct. benzoin comp., and cover over with lead-foil and a bandage, 
is an excellent method of dealing with this variety of sore. 

The unguentum resinse is a valuable dressing for this and the follow- 
ing form of ulcer : 

The typical indolent ulcer goes by many names, and an infinite 
variety of treatments has been recommended for it. Stimulation must 
here be severe; the application of the solid nitrate of silver seldom suc- 
ceeds except in very mild cases. When possible, the patient should lie 
up, so as to get the treatment well started. The first step in treatment 
is to thoroughly cleanse the often foul, greenish-colored watery surface, 
and get rid of every trace of dead matter by carbolic or corrosive sub- 
limate in very weak solution. Poultices, so often recommended, are 
not to be applied ; much more will be obtained by antiseptics under 
oiled silk, and very frequent and very thorough bathing. 

The edges in all chronic cases are raised and callous and of almost 
cartilaginous consistence, so that this type of sore is often called the 
callous ulcer. As long as these edges remain in this condition recovery 
or healing is not possible. 

Before resorting to severe measures pressure may be tried, and some- 
times, even in most unpromising cases, the skilful use of the Martin's 
India-rubber bandage acts like a charm. It may be applied direct to 
the face of the ulcer without any intervening dressing. The patient 
should apply it himself every morning before leaving bed, and he soon 
gets to feel the requisite amount of tension, which increases as he 
assumes the vertical position. The bandage is kept on all day and 
not removed until the patient is flat in bed. It is then washed in a 
basin of water containing a trace of some antiseptic. The ulcer is to 
be likewise carefully cleansed, and a thick pad of lint soaked in spirit 
or carbolic lotion placed over it until morning under a plain calico or 
stocking-web bandage. The skin of the limb is generally found so 
macerated and tender that it will not be advisable to cover in the night 
lotion by oiled silk, though this may sometimes be done to advantage. 

Sheet-lead, cut a little larger than the ulcer, may be laid over one 
or more plies of lint soaked in weak corrosive sublimate or any other 
lotion and placed upon the surface of the ulcer, the whole being cov- 
ered by a pad of lint or gauze and kept in position by elastic webbing 



882 ULCER. 

or woven India-rubber bandage as just described. Excellent results 
follow this method where the pure rubber bandage cannot be tolerated. 

Watson, of Boston, modifies this plan by laying a piece of protective 
over the face of the sore after thoroughly disinfecting it with a 1 : 4000 
corrosive sublimate solution ; over this he places a piece of sheet tin, 
the whole covered by a dry corrosive sublimate gauze dressing held in 
place by an evenly applied bandage from the toes to the knee. The 
lead-foil and woven-rubber bandage are better. Where these plans 
fail after a good trial, during which the patient may be permitted to 
follow his avocation (this is the great value of the method), other 
measures may be tried. 

Blistering of the ulcer and its margins is recommended, but this is a 
painful and often useless plan and may possibly cause sloughing. 

The best treatment at this stage is to take a sharp bistoury and make 
a series of alternately deep and shallow linear incisions through the 
thickened or callous margins, radiating outward from the centre of the 
ulcer like the spokes of a wheel from the nave. The deep incisions 
should penetrate the deep fascia and extend for an inch or two beyond 
the margins of the ulcer. Bleeding is easily stopped by pressure. 
This method is more successful than paring down the edges of the sore. 
The writer thinks it was first practised in the Edinburgh School, and 
he has seen its great success in many cases in the hands of an old pupil 
of Syme. 

Harbordt, apparently independently, has introduced a slight modi- 
fication of this method, which is thus described by Spaeth : 

" The entire ulcer is divided lengthwise by a deep incision, extending 
far into the healthy tissue. Cross incisions are then made through the 
callous tissue into the healthy at intervals of about three-quarters of an 
inch. The incisions must go through, not only the skin, but the under- 
lying fascia ; the wounds must gape widely. The bleeding, often pro- 
fuse, must be stopped with tampons; and the whole wound, which it 
must be owned has rather a slaughter-house look, is done up with 
iodoform dressings. When, after eight to fourteen days, the dressing 
is changed, the difference in appearance is very marked. Healthy 
granulations are springing up in abundance from the gaping incisions, 
and soon cover the whole surface reaching the level of the surrounding 
skin from which the growth of new epidermis is seen to advance 
rapidly." 

Scraping of the ulcer may be tried before resorting to this procedure 
in some cases, where the edges are not very thick and raised. 

Strapping of the ulcer should be mentioned. It is, however, seldom 
needed now, as all that it can possibly do is better done by the elastic 
pressure of Martin's bandage. 

Skin grafting may be needed where the ulcer is extensive, but it is 
useless to attempt the operation until the entire nature of the sore has 
been first altered by some of the above plans. Sponge grafting has 
very often failed. The skin grafts should be very small. Though 



ULCER. . 883 

they may be numerous, they do best when planted inside the edges of 
the sore. 

Unna's treatment of chronic ulcers of the leg is applicable to the 
simple, indolent, and varicose forms. The leg is washed with soap and 
water and covered over everywhere, except at the ulcerated spot, by a 
paste consisting of 1 part of pure gelatin, 1 part of oxide of zinc, 4 
parts of glycerin, and 4 parts of water. Iodoform is then freely 
sprinkled over the ulcer, which is afterward to be covered with any 
antiseptic gauze laid over a layer of cotton- wool. Over all are applied 
two double-headed wet mull bandages with their ends crossing in front. 
They should extend from the middle of the foot to the calf. Once or 
twice a week will be in the majority of cases sufficiently often for 
changing the dressings, but when the discharge is profuse this may be 
necessary every second or third day. Hildebrand, who has obtained 
excellent results from this method, claims for it that it draws the healthy 
skin toward the ulcerated margins and rapidly facilitates healing. 

Electricity may be utilized in various ways for the healing of very 
chronic ulcers ; the most convenient and simple plan is that devised by 
Bird, and described upon page 66. He covers over the ulcerated spot 
with a disc of silver, attached to a plate of zinc by means of a wire. 
The zinc disc is placed over the neighboring skin from which it is 
separated by a layer of wash-leather, soaked in vinegar. 

Papain has been used to cause disintegration of the thickened edges 
of very chronic ulcers, and several surgeons have tried to establish 
healing by inducing inflammation by means of jequirity infusion or a 
paste (1:4) of the powdered seeds, but, as a rule, the results have been 
unsatisfactory. 

The writer has seen very decided benefits follow the fumigation of 
the ulcer by means of calomel vapor. In syphilitic ulcers this appears 
to act sometimes like magic, but in nearly all forms and varieties of 
chronic ulcer its benefits are most striking. The patient lies in bed, 
and the calomel is put into the receptacle in the apparatus used for 
giving a hot-air bath in Bright's disease (this is briefly described upon 
page 74), and the calomel vapor is conducted under the bed-clothes by 
a narrow tin tube whose extremity is placed immediately opposite the 
ulcerated surface. 

Where all plans fail, and the ulcerated surface has been permitted 
to involve a large area of the leg surface, amputation may be the only 
alternative to a bed-ridden career. 

In such cases Bell Keatley's operation is a distinct advance. He 
scrapes the ulcer thoroughly, removes the bones and soft tissues of the 
dorsum of the foot, and transfers to the site of the ulcer the whole of 
the sole of the foot, including muscles, plantar vessels, and nerves, and 
excluding loose tendons after removing a small portion of the lower 
end of the tibia. The result is a good stump, like a Syme, instead of 
an ordinary amputation at the knee. He also preserves the dorsal foot 
flap for ankle amputations in cases of complete circular ulcer of the leg 



884 . • ULCEK. 

by bending it round upon its neck and covering with it the ulcerated 
surface. (See Lancet, November, 1885, and February, 1890. 

It must always be kept in mind that, though the local treatment of 
the indolent ulcer is most important, little advance can be made unless 
constitutional measures be closely attended to. This is true also as 
regards all forms of chronic sore. Healing may be impossible until 
good food in abundance, with tonics, pure air, and every means by 
which the nutrition of the body can be improved, have got a fair trial. 

The irritable and the inflamed ulcer are often very difficult to deal 
with, and the measures already mentioned are contra-indicated until 
all pain and tenderness are removed, as stimulating lotions or ointments, 
or the pressure of the rubber bandage, will ouly aggravate the patient's 
suffering. 

Absolute rest in the horizontal position is essential. Generally the 
administration of purgatives affords some relief, and the effect of half 
a minim of croton oil is often very striking ; it appears to possess some 
specific action over the irritable ulcer. 

The writer has seen the pain and discomfort associated with the 
irritable ulcer yield rapidly to the-following pill, which is a modifica- 
tion of Plummer's pill : 

R .— Hydrarg. chlor. mitis gr. jss. 

Antimonii sulphurati gr. ij. 

Eesinse guaiaci . . , gr. ij. 

Oleitiglii . . . . . . . . trU--M. 

Make 24 of these. 

8. — Take one pill every night and morning for three days, then one occa- 
sionally. 

Saline purgatives are to be preferred in the case of the inflamed 
ulcer where there is much pain, heat, redness, and swelling in its 
margins. 

Constitutional remedies for the relief of pain may be indicated, but, 
as a rule, opium and other narcotics are not to be employed except to 
produce sleep at bed-time. A combination of bromide of sodium (30 
grains) and antipyrine (5-10 grains) may be given two or. three times 
a day when the pain continues to disturb the patient. 

Locally the irritable ulcer may be best treated by carbolic lotion 
(1 : 30) under oiled silk. When this fails, 2 per cent, cocaine solution 
may be tried. If this latter does not give immediate relief it may 
be rejected, and a lotion of chloral hydrate (1 : 200) may get a trial. 
The old lead and opium lotion under oiled silk may do well, but very 
often every sedative application appears only to aggravate the pain. 
Under these circumstances by far the best plan to pursue is to apply a 
strong solution of cocaine (8 per cent.) for fifteen minutes, after which 
the ulcer and its edges are to be well painted over with the strongest 
solution of nitrate of silver (60 or 80 grains to 1 ounce), or the solid 



ULCER. 885 

stick may be used. After cauterization, soothing evaporating lotions 
may be used for a few days, when the ulcer may be regarded as a 
simple sore, and treated by the agents already enumerated. 

The inflamed ulcer is best dealt with by cold evaporating lotions and 
the elevation of the limb after saline purgatives have been used to 
establish a free discharge from the bowels. A few small incisions with 
a sharp-pointed tenotomy knife will give better results than leeching, 
and in very severe cases one poultice may be applied to encourage the 
bleeding from the incisions, but poulticing, as a rule, is bad practice in 
the treatment of ulcers. 

Sloughing ulcers call for supporting and stimulating constitutional 
treatment. They occur in intemperate and often in syphilitic subjects, 
and the agents indicated in phagedena may be demanded. Thus 
opium, alcohol, tonics, concentrated beef essences and jellies must be 
given freely. 

Local treatment will depend upon the peculiarities of the case. 
Thus, if the sloughing process seems to be spreading, a free application 
of the strong nitric acid may be demanded, but if the process appears 
to be at a standstill, measures which hasten the separation of the 
slough will be indicated. Weak antiseptic lotions, as corrosive subli- 
mate (1 : 5000), permanganate of potassium (1 : 1000), nitric acid 
(1 : 3000), or carbolic acid (1 : 60), may be used to irrigate the sore 
and its immediate vicinity. 

After constitutional measures have been used, and the patient's gene- 
ral condition improved, the ordinary applications suitable for a simple 
healing ulcer may be employed. 

Varicose ulcers are [those occurring upon the limbs, the seat of a 
varicose or enlarged condition of the veins. The term is a bad one, 
as any form of ulcer may be and generally is classed as varicose 
when occurring under these circumstances. The appearance of the 
sore will give indications for the employment of some of the previously 
mentioned plans of treatment. As a rule, however, little progress w T ill 
be made unless the condition of the veins is specially attended to. 
Rest is essential, and, if the ulcer be not irritable, this may be accom- 
plished without sending the patient to bed if a good rubber bandage 
can be worn during the day-time. 

Many, therapeutists still believe that hazeline or hamamelis exerts 
some specific action upon the coats of veins, and hence a lotion con- 
sisting of equal parts of hazeline and water is a favorite application 
to the so-called varicose ulcer. The writer uses the Martin's bandage, 
applied directly to the limb, during the day, and the following lotion 
at night under oiled silk : 

R. — Spt. vini rectif. ^ij. 

Hazelini . . . % iv. 

Aquse rosse Jij. — M. 

S. — To be applied to the sore spot upon lint and covered over with oiled silk. 



886 URINARY FISTULA. 

Eczematous ulcers are generally a variety of the last mentioned, as 
they are nearly always associated with varicose veins. Their treat- 
ment is often very troublesome, and will depend upon the stage of the 
eczema present. If the case is of long standing and the eczema be 
scaly, the rubber bandage may be tried cautiously. If the patient can 
tolerate it without uneasiness, it may be found to remedy the three 
abnormal conditions at the same time — viz., the varicose veins, the 
ulcer, and the eczema. Unfortunately, however, it will be found 
sometimes to increase the eczema by preventing the escape of the 
secretions of the skin and of the ulcer. Two courses will then be open 
— either to send the patient to bed and treat the eczema and ulcer, or 
to resort to the woven rubber bandage described upon page 879. Under 
this appliance any suitable eczema remedy may be applied to the limb, 
while the patient is permitted to pursue his ordinary avocation. 

As a rule, in the eczematous ulcer, moist applications under oiled 
silk should be avoided. Under the woven rubber bandage, powders 
like oxide of zinc, starch, bismuth, etc., can be applied if there be 
much secretion ; or stimulating ointments like tar, basilicon, or the 
valuable combination given in the recipe upon page 229, may be spread 
upon lint and laid in contact with the sore. 

The rubber bandage should be always worn after the healing of the 
ulcer, or the veins may afterward be tied and cut, so as to radically 
remedy the varicose condition. 

URINARY FISTULA. 

As this condition is generally a sequel to stricture of the urethra, 
abscess of the prostate gland, or extravasation of urine from traumatic 
causes, the treatment of the primary condition will call for surgical 
interference. 

The affection varies widely in different cases owing to the route taken 
by the original urinary abscess. Thus only one sinus about the scro- 
tum or perineum may exist, while as many as thirty openings have 
been seen studded over the same region and extending into the rectum 
and above the groins. The treatment will, therefore, necessarily vary 
considerably. 

Given a simple fistula, opening at the one extremity into the urethra, 
and at the other into the perineal region, it will be found, in the great 
majority of cases, to be secondary to a stricture of long standing. Such 
a fistulous opening, even when of long duration, will, as a rule, heal as 
soon as the urethral stricture is properly dilated. Under the heading 
of Stricture of the Urethra, upon page 795, the various plans of deal- 
ing with the primary affection have been detailed, and need not be here 
repeated. As a rule, it will be wise tj begin with solid metal bougies, 
passed every two or three days, until the fullest size which the urethra 
is capable of taking is reached. 

In many instances, however, it will be found that the anterior end 



URINARY FISTULA. 887 

of the stricture will only admit the finest instruments after much diffi- 
culty, and under these circumstances it will be necessary to begin with 
filiform bougies or soft catheters passed down the urethra, and coaxed 
into the bladder. When the bladder has been entered the instrument 
should be tied in, and after twenty-four or forty-eight hours a larger 
one may be made to take its place. 

"When about No. 6 English size is reached, the dilatation may be 
further carried out by the interrupted method of passing the larger 
graduated solid metal sounds, which will enable the patient to go about 
and pursue his ordinary avocation. 

In some cases the fistula will be found to still remain open after full 
dilatation has been accomplished, and after waiting a reasonable time, 
the surgeon must resort to other methods. The cause of failure in 
such cases always depends upon a small quantity of urine finding its 
way into the fistula each time the patient makes water. This keeps 
the tract green, and prevents healing. As a rule, the plan of injecting 
irritants or caustics along the fistulous tract in such cases is bad prac- 
tice, though still advised by some surgeons. The practice of tying in 
a large catheter in the bladder is still worse. The best procedure by 
far is to teach the patient to pass a large- sized soft instrument, and 
caution him not to attempt to make water without its aid upon any 
occasion. Even before having a motion from the bowels he should 
immediately pass his catheter, and draw off every drop of urine. In 
this way all trickling of urine along the fistulous tract is completely 
prevented, and in a short. time complete closure results. The use of 
the catheter may then be discontinued. 

This method will also be found to be efficacious in those cases of 
urinary fistula caused by prostatic abscesses. 

Where two, three, or four openings lead direct from the perineum 
into the urethra without much induration or any diverticula, success 
may follow the above line of treatment. When, however, the tracts of 
the fistulse are in connection with regions riddled by small abscesses, 
the perineum must be opened by a free external incision made over a 
Syme's staff for perineal section. 

In those cases where from the first the stricture is impassable by any 
instrument introduced along the urethra, the treatment, so successful 
in simple cases, cannot, of course, be pursued. There is nothing left 
in such cases for the surgeon but to cut down upon the seat of stricture 
by perineal section, and by the Boutonniere operation the urethra may 
be divided upon a Wheelhouse's straight-grooved steel staff. In some 
cases Cock's operation may be performed, and the urethra divided 
behind the stricture, in its membranous portion. 

Wheelhouse's operation is the best for most cases, and it is described 
along with the other methods under Stricture of the Urethra upon 
page 801. 

The after-treatment may require the continuous use of the soft rubber 
catheter passed into the bladder upon every occasion by the patient 



UTERINE DISPLACEMENTS. 

when urine is to be voided. This must be perseveringly adhered to 
until after the openings have entirely closed up. 

The internal use of boric acid in fair doses is of great value in cor- 
recting the condition of the urine, and it is needless to say that the 
closest attention must be paid to diet and general hygiene. 

URINE, Retention of— See Retention of Urine, page 741. 

UTERUS, Diseases of. 

The treatment of the different diseased conditions of .the womb have 
already been detailed under their several headings. Thus, for the 
agents indicated in dealing with inflammation of the lining membrane 
of the organ, the reader is referred to the brief article upon Endo- 
metritis, pages 241-244. For the treatment of inflammation of the 
womb, he is referred to Metritis, page 508. The management of 
cancer of the womb will be found under Cancer of the Uterus, upon 
pages 106-109. 

Hemorrhage from the uterus is referred to under Menorrhagia and 
Metrorrhagia, pages 504-506. Post-partum hemorrhage and the 
remedial agents used in its prevention and treatment will be found 
upon pages 315-318. 

Ulceration of the cervix or os is generally found associated with 
granular degeneration, and yields, for the most part, readily to the 
treatment mentioned under Leucorrhoea, which is so constantly asso- 
ciated with it. Where these measures fail, however, as they do in 
some cases, the eroded surface should be touched by some strong 
caustic through the speculum by means of a Playfair's probe. Almost 
every caustic has been used for this purpose. The writer advises as a 
routine agent iodized phenol (1 part of iodine dissolved in 4 parts of 
carbolic acid). The following are efficient applications : Nitrate of 
silver in solid stick, nitric acid, pure carbolic acid, chloride of zinc, 
solution of nitrate of mercury, or of chloride of iron. Tampons of 
cotton wool saturated in glycerin, or, as the writer recommends, in the 
glycerin of borax (1 : 4) (made without water), or in the glycerin of 
tannic acid or of alum (1 : 6) may be used with great advantage. 

UTERINE DISPLACEMENTS. 

The treatment of these ailments has been a source of controversy 
almost as fertile as has been their pathology. The physician who be- 
lieves that the displacement is the primary cause of the symptoms which 
are often present contents himself with the various mechanical con- 
trivances invented to keep the uterus in its normal position. 

Upon the other hand, those who regard the displacement itself as 
secondary to some previous mischief content themselves by seeking 
out the primary cause of the departure from the normal, and treating 
it. There are others, however, who, while fully recognizing that some 



UTERINE DISPLACEMENTS. 889 

abnormal condition of the uterus always underlies the displacement, 
believe that, after this has been remedied to the fullest extent, the 
organ may require to be kept in its proper position by an accurately 
fitting pessary. 

The writer believes that the best results in treatment will follow the 
use of measures directed under a proper appreciation of this last-men- 
tioned view of the case. The subject is, however, one which can only 
be very briefly referred to in the narrow limits of the present volume. 
The treatment of prolapse of the uterus has been fully dealt with 
already upon pages 702-705. 

Retroflexion of the uterus is the most common of the abnormal posi- 
tions of the organ demanding treatment, though it may often exist 
without producing any inconvenience or symptoms. 

The primary mischief should be carefully searched for ; some en- 
largement of the uterus, the result of chronic inflammation, which 
has led to hypertrophy and softening of the uterine walls, may be 
detected. 

Atthill's view may be broadly accepted — viz., that the healthy uterus 
will not bend. 

The enlargement may be simply the result of subinvolution after 
profuse menstruation or parturition, and the heavy organ may assume 
its normal position when it becomes reduced in weight. It may be the 
result of a tumor growing in the interior of the organ or imbedded in 
its walls. 

It will, therefore, be obvious that these causes should, when possible, 
be remedied if they still remain. Thus pain, heat, and tenderness 
must be met by the agents detailed under Metritis, upon page 508, if 
the uterus cannot be replaced in its normal position without increase 
of pain and discomfort. 

Rest in bed, hot douches, and the glycerin tampon very speedily 
remove local tenderness, after which an effort should be made to 
replace the uterus. This is generally accomplished without difficulty 
by the insertion of the middle finger into the rectum, and the index 
finger into the vagina. Should this plan fail, the organ may be re- 
placed by passing a sound through the os, taking care to use only very 
gentle force. The manoeuvre of placing the uterus in its normal 
position may be repeated several times with the interval of a few days. 
As a rule, it will be found that it speedily resumes its abnormal posi- 
tion again. 

A vulcanite Hodge's pessary should be inserted, the upper convex 
end of the instrument being lodged well behind the cervix in the pos- 
terior fornix. Speedy relief very often follows the replacement of the 
organ and the introduction of the pessary, which may be worn for ten 
or twelve weeks at a time if it keeps in position and causes no pain or 
discomfort. Its presence need not interfere with the constant employ- 
ment of the vaginal douche. 

Though it may be impossible to keep the uterus in its normal posi- 



890 UTERINE DISPLACEMENTS. 

tion by this form of pessary, it is the experience of every physician 
that great benefit may be obtained from its use through the support 
which it gives to the parts. After three to six months it may be re- 
moved, and the position of the uterus carefully examined after the 
lapse of a few days. If the retroflexion is found to occur upon the 
withdrawal of the support, it must be again inserted and worn until 
the uterus keeps the normal position after its removal. 

Innumerable modifications of the above-mentioned pessary have been 
introduced, some of which may occasionally be indicated uuder excep- 
tional circumstances. Thus Greenhalgh's spring instrument and Albert 
Smith's modification may be selected. Vulcanite is, as a rule, to be 
preferred to gutta-percha or rubber-covered metallic pessaries. Various 
flexible and stiff stem pessaries have been advocated in the treatment 
of retroflexion, but their use had better be confined to the hands of 
specialists. It is, moreover, hardly necessary to say that no attempt 
should be made to restore the uterus to its normal position if there are 
reasons for believing that the organ is bound down by adhesions in its 
retroflexed position. 

Retroversion, which generally exists to some extent in most cases of 
retroflexion, is occasionally met with alone. The treatment will be 
conducted upon the same lines, viz., the remedying of all abnormal 
conditions, as metritis, subinvolution, tumors, congestion, etc., and the 
use of a Hodge's pessary to give support to the replaced organ as just 
mentioned under Retroflexion. 

Where pregnancy complicates the case, the retro verted organ must 
be carefully replaced, and the catheter used twice a day where symp- 
toms of retention supervene. 

Anteflexion of the uterus. The displacement is to be treated upon 
the principles already mentioned as applicable to all uterine flexions 
or versions. The inflammatory, congested, hypertrophied, or subinvo- 
luted organ must be restored to a natural condition, as far as this is 
possible, by suitable agents, as rest, glycerin tampons, and hot vaginal 
douches ; ergot internally, and agents employed with the view of sub- 
duing pelvic inflammation, may be necessary. 

Puncture, leeching, or division of the cervix, and the regular intro- 
duction of the uterine sound have been advocated and successfully 
practised. Pessaries, as a rule, fail. The writer has a few times suc- 
ceeded with Graily Hewitt's anteversion pessary, and he has satisfied 
himself that this instrument, when it does give relief, does so by steady- 
ing the uterus as a whole, or by its presence exciting some reflex action 
which assists in improving the tone of the pelvic floor. He has seen 
excellent results with this cradle pessary when inserted upside-down, 
both in anteflexion and retroflexion. 

When inserted in this inverted way it steadies the uterus and is 
scarcely capable of being displaced. It is, however, most difficult to 
introduce and to withdraw. 

Many authorities highly recommend the intra-uterine stem pessary 



UTEKINE DISPLACEMENTS. 891 

of rubber, or the galvanic stem or glass stem pessary, and where the 
rubber or gutta-percha instrument of Greenhalgh can be comfortably 
tolerated, it may do good. The writer believes, however, that the only 
cases where it probably will do good 'are the mild cases which will get 
well without any appliance whatever. 

Anteversion, which is generally a direct result of inflammation of 
the uterus or its lining membrane, or of pelvic peritonitis, or of pelvic 
cellulitis, may be best treated by agents directed against these lesions. 
(See under the heading of each.) 

When the cause has been fairly dealt with and all pain and tender- 
ness removed, the cradle pessary just mentioned may be inserted with 
its convexity looking upward, as originally intended. Sometimes a 
Hodge seems to meet all the requirements of the case. Thomas's ante- 
version pessary may succeed, but, as a rule, stem pessaries should not 
be thought of. 

Inversion of the uterus is a very serious displacement. Occurring 
immediately after delivery, if observed at the time, its reduction may 
be effected without much difficulty. The placenta should be at once 
removed and the organ returned to its normal position by inserting the 
right hand into the vagina and pushing up the uterus against the left 
hand, applied outside the abdominal wall. 

In cases where the displacement has been overlooked for any time, 
the process of reduction may be very difficult, tedious, or impossible. 
The pressure by the hand may have a fair trial under chloroform be- 
fore resorting to other methods ; and if the uterus cannot be returned 
to its normal condition, reposition or reduction may be then tried by 
the use of White's reducing appliance, which consists of a disc fas- 
tened to a spiral spring by means of a curved iron rod. The disc or 
cup is carried up into the vagina and placed in contact w r ith the fun- 
dus, against which it is held firmly by the hand in the vagina. The 
spiral coil of wire is held against the breast of the operator, on the 
same level as the uterus, and steady, even pressure is thus kept up 
upon the fundus, which gradually is reposited with the assistance of 
the operator's free hand applied to the abdominal wall above tne 
pubes. 

Other plans are practised, one of which is to dilate the urethra so as 
to admit a finger into the bladder, while another finger is introduced 
into the rectum, and pressure applied in this way upon the anterior 
and posterior margins of the depressed rim, while counter-pressure is 
applied to the fundus from without. 

Emmet's plan is to push the fundus up until it can be enclosed by 
the os, which latter is then closed by sutures after paring off its mar- 
gins. 

The gradual method of reposition may be tried. It consists in in- 
troducing a rubber bag into the vagina, in contact with the fundus. 
Water is then slowly forced into the bag by hydrostatic pressure, and 
by this slow, even pressure the fundus is gradually returned. 



892 UTERINE DISPLACEMENTS. 

The same principle may be carried out by using the hollow cup of 
Thomas, which is applied to the os, as in the case of White's repositor, 
but the pressure is made by elastic cords attached to the stem of the 
cup and to an abdominal bandage. 

When all these measures fail, amputation of the inverted uterus 
with the knife or galvano-cautery may be resorted to. 

URTICARIA— See Erythema, page 259. 

VAGINISMUS. 

In very mild cases the application of emollients or local sedatives 
may have a trial before resorting to operative interference. As a rule, 
however, little is to be expected from this plan if the symptoms are 
severe. The following may be tried : 

Be . — Cocainse purif. . . gr. xxx. 

Morphinse purif. gr. xv. 

Unguent, conii ^j. — M. 

S. — A little to be smeared over the painful spot with the finger. 

Or the following medicated pessary may be tried : 

R . — Cocainse purif. gr. j. 

Iodoformi . gr. x. 

Ext. belladonna? . . . . . . . gr. jss. 

Olei theobromatis q. s.' 

Where speedy relief does not follow the use of these local applica- 
tions, a careful inspection of the vaginal orifice should be made, and any 
abrasions, fissures, or ulcers should be incised or removed by knife or 
scissors after the application of a strong cocaine solution, or under the 
influence of chloroform. The remains of the hymen should be care- 
fully cut away by the scissors. 

No operative interference, however, is of any avail unless the 
vaginal orifice be dilated to its widest extent. This may be done by 
inserting the thumbs and forcibly rupturing the muscular fibres by 
strong traction. Afterward a large vaginal bougie or a glass dilator 
shculd be introduced and worn by the patient for half to one hour 
twice daily. 

In severe cases Sims's operation must be performed. This is carried 
out under chloroform by making an incision two inches long upon each 
side of the vaginal orifice, down through the mucous membrane, and 
dividing the superficial part of the muscular fibres. The incision 
should extend from above the level of the ostium to the raphe of the 
perineum. The vaginal orifice is to be dilated forcibly by the fingers, 
and if there be much hemorrhage, the canal should be firmly 
plugged. 



VARICELLA — VARICOCELE. 893 

The glass dilator must be worn during healing at least once a day. 
In a very severe case under the care of the writer, Atthill removed 
entirely, with marked success, a narrow strip of mucous membrane on 
each side of the vaginal orifice. 

VARICELLA. OR CHICKEN-POX 

In the vast majority of cases requires no treatment. In rare cases 
where the affection is severe, rest in bed and the administration of a 
mild diuretic, with occasional sponging of the skin with a weak 
alkaline solution, meet all requirements. 

VARICOCELE. 

Palliative measures always should have a fair trial in this condition 
before operative procedures are thought of, unless the case be very 
severe or of long standing, or where the subject of it is exposed to 
severe physical exertion, or where he wishes to enter into some de- 
partment of the Government service. 

Change of occupation has led to the disappearance of the varicose 
condition of the scrotal veins in several instances under the writer's 
notice, where the patient relinquished an occupation compelling him 
to stand the entire day, for one entailing a considerable amount of 
sitting, with some open-air exercise. In all cases the scrotum requires 
the support of a good suspensory bandage; constant bathing and 
sponging of the skin does good. The writer has satisfied himself that 
great benefit may be obtained by kneading the scrotum between the 
finger and thumb several times a day so as to excite contraction of 
the muscular elements. This is especially valuable in those cases 
where the scrotum is very lax and toneless. Lotions are of little use, 
as they must be covered in with oiled silk, when they soon act as poul- 
tices. The following may be sponged over the scrotum every morning 
before the patient begins to dress : 

Be. — Hazelini ^iij. 

Alcoholis ifijss. 

Aquae de st ^ivss.— M. 

Constipation must be prevented, and sexual excitement and ex- 
cesses guarded against. Electricity may have a trial ; a weak con- 
tinuous current passed through the moistened scrotal integument 
morning and night, combined with massage, greatly assists in improv- 
ing the tone of the part. The wearing of a truss with the intention of 
compressing the spermatic veins in the inguinal canal is to be con- 
demned. It may greatly aggravate the condition. 

Internal agents as ergot, hamamelis, and other drugs supposed to act 
upon the bloodvessels are useless, but there is no doubt that any good 
tonic which improves the general tone will assist the varicocele to dis- 



884 VARICOSE VEINS — VARIOLA. 

appear. Quinine, iron, and strychnine in combination, as in Easton's 
syrup, may have a fair trial. 

Where these agents fail in improving matters, operative measures 
should be considered, especially if there are auy signs of wasting of 
the testicle on the affected side. 

Operative plans consist in the subcutaneous division of the enlarged 
veins. Lee's operation is carried out by passing two needles through 
the scrotum beneath the enlarged veins, at a distance of half an inch 
from each other, and a figure-of-8 ligature is applied over each, after 
which the veins between them are divided subcutaneously. Another 
plan is to surround the veins by a subcutaneous loop, by passing a 
needle armed with a catgut ligature ; after tying, this may be cut close. 
If this latter plan be adopted, the veins may be ligatured in several 
places subcutaneously, and their continuity destroyed between the liga- 
tures by cutting them across. Some surgeons excise the enlarged 
veins completely, while others effect their destruction by subcutaneous 
division by means of the galvanic ecraseur. 

VARICOSE VEINS 

Should be treated upon the principles already detailed under Ulcers, 
on page 880. Support to the dilated vessels by means of a properly- 
applied pure rubber bandage affords by far the best treatment for this 
condition. The bandage should be applied from the toes to the upper 
limit of the varix before the patient assumes the vertical position in 
the morning, and it should not be removed until he lies down in bed 
at night. Where the skin gets tender under its use, a perforated rub- 
ber bandage may be employed, but the elastic webbing described upon 
page 880 meets every requirement. These appliances are vastly supe- 
rior to the old-fashioned elastic stocking, which should never be recom- 
mended unless when the patient refuses to take the trouble of employing 
a rubber bandage. The writer has obtained good results by the appli- 
cation of the elastic webbing or a pure rubber bandage over an ordinary 
silk or cotton stocking. 

Prolonged standing, the use of garters, chronic constipation, and 
anaemia or plethora should be guarded against, and everything calcu- 
lated to improve the general health and diminish venous engorgement 
must be attended to. 

Where these measures fail, the veins must be excised or ligatured. 
The best results are obtained by ligaturing the vein in several places, 
and dividing it between the ligatures. 

VARIOLA. 

The treatment of smallpox differs in no way from that of the other 
eruptive fevers. The principles of treatment as applied to the man- 
agement of measles (pages 489-492), of typhoid fever (pages 860-876), 
and of typhus (pages 876-879), maintain also in the treatment of this 



VARIOLA. 895 

affection, and need not be again enumerated in detail. They have 
been also enumerated under Scarlatina. 

The sanitary surroundings of the patient demand the most careful 
attention, not only on account of the highly infectious nature of the 
disease, but also because of the extensive suppuration. Hence the 
most rigid isolation and the necessity for thorough ventilation. The 
details referring to the choice and arrangement of the sick-room and 
the patient's bed should receive special care. 

In severe cases, as in confluent smallpox, the pain in the back may be 
relieved by small doses of antipyrine, administered, not with the view 
of producing a fall in the temperature, but with the intention of 
obtaining t he analgesic action of the drug. For this purpose the dose 
should not exceed 5 grains, nor need the remedy be pushed for more 
than twenty-four or thirty-six hours. J. W. Moore, in his recent valu- 
able contribution to medicine, advises for this purpose dry-cupping 
and the use of the India-rubber hot-water bag. 

For the general condition there is no special treatment. At present 
we do not know of any agent possessing specific action over the dis- 
ease. Antiseptic drugs have been extensively employed with the view 
of destroying the organism causing the fever, but it does not yet appear 
that any marked results have been obtained. Sansom's plan of admin- 
istering the sulphite of sodium in 20 or 30 grain doses, or the sulpho- 
carbolates in similar quantities, can do no harm ; and though they have 
generally failed in making any very decided impression upon the con- 
stitutional symptoms, they may possibly sometimes turn the scale in 
the struggle against the microbe. Yeo has forcibly shown that slight 
modifications in the environment of the parasite may materially modify 
its activity. Carbolic acid, corrosive sublimate, and salicylic acid have 
been extensively employed, and of the latter drug Baudon has reported 
successes. 

J. W. Moore, as the result of his extensive experience, states that in 
quinine in 5 grain doses and in tincture of chloride of iron in 20 to 30 
minim doses we possess the two most valuable antiseptics known, so 
far as smallpox is concerned. Bianchi carries out the antiseptic treat- 
ment to the fullest extent, with apparently excellent results (no deaths 
in ninety-six cases). He renders the surface of the patient, his bed- 
ding, room, and all his surroundings as aseptic as possible. 

Various antiseptic solutions have been recommended for sponging 
over the body. The writer would strongly recommend inunction of the 
patient's skin with the oil of eucalyptus from the very commencement 
of the disease. 

The mineral acids internally, as in the other eruptive fevers, give 
very good results, and in mild cases or modified smallpox should con- 
stitute the only treatment. 

Alcoholic stimulants are to be administered when necessary, the in- 
dications being identical with those already fully discussed upon pages 
869-872. When free suppuration occurs, stimulants in conjunction 



VARIOLA. 

with large amounts of concentrated nourishment must be given at short 
intervals. 

In the hemorrhagic variety of the disease, large doses of iron and 
quinine must be administered by the mouth, while ergotine is given by 
deep parenchymatous injection, and turpentine by the bowel. 

The following is the formula used by Dr. Moore at the Cork-street 
Hospital : 

Be. — Ext. ergo tse fid. giij. 

Olei terebinthinse . . . . . . giij. 

Spt. setheris nit. 3ij- 

Spt. vini rect §j. 

Ovi vitellum. 

Aquae menthse pip . ad ^viij. — M. 

S. — One-eighth part every third, fourth, or sixth hour, as required. 

The treatment of such complications as headache, delirium, insomnia, 
and diarrhoea is already detailed under Typhoid Fever. 

The local treatment of the eruption is of the utmost importance, 
especially upon the face, and there is practically no end to the list of 
methods recommended with the view of preventing pitting. 

Stokes laid down three indications for treatment which are accepted 
by J. W. Moore and other authorities. He insisted upon the exclusion 
of air ; the keeping of the parts in a permanently moist state, so as to 
prevent the hardening of the scabs ; and the lessening of the local irri- 
tation. 

He carried out these indications by the application of poultices — a 
plan which has, however, steadily diminished in favor since the intro- 
duction of the antiseptic methods of treatment. 

Any unirritating antiseptic solution may be applied upon lint cov- 
ered by oiled silk. Thus, boric acid (1 : 100) is a favorite application 
either covered by oiled silk or used as an evaporating lotion. 

Weak corrosive sublimate solution (3 grains in 10 ounces) has been 
used by Skoda and Hebra. Carbolic lotion (1 : 80), carbolized oil 
(1 : 8), and carbolic pastes made with chalk and oil are highly recom- 
mended. 

As a rule, thick oily preparations are more valuable than watery 
solutions. The writer recommends the following : 

K. — Linimenti calcis ^vijss. 

Olei eucalypti 3 iv. 

Calamine prsep. gj. — M. 

S. — To be applied with a large camers-liair brush to the skin of the face 
every two or three hours. 

Tincture of iodine has been extensively used by brushing over the 
papules until the free suppuration stage has occurred. 



VOMITING — WARTS. 897 

Mercurial ointment, diluted with 5 to 15 parts of lard, has been tried 
and reported upon favorably. It is not without serious danger. A 
very innocent plan is to smear over the face with olive oil, and then to 
apply a powder consisting of equal parts of subnitrate of bismuth and 
prepared chalk (Hamilton, of Illinois). 

Lewentauer applies upon a mask of lint an ointment consisting of 
salicylic acid, 1 drachm; starch, 10 drachms; and glycerin, 4 ounces. 

The plan of rigidly excluding daylight from the sick-room has some 
advocates in America, but it is manifestly objectionable, and by no 
means certain in its effects. Better results may be obtained by cover- 
ing the face with a mask upon which any of the previously mentioned 
agents is spread. 

Collodion, traumaticine, gold leaf, cauterization of the vesicles by 
solid nitrate of silver, or their evacuation by means of a fine needle, 
and many other plans formerly in vogue, are not to be recommended. 

Moore covers the face by a light mask of lint soaked in a mixture 
of iced water and glvcerin (8 : 1), and covers over the mask with oiled 
silk. 

Sprays of any of the above substances may be employed. A weak 
carbolic spray has many advocates, but it is difficult to see how it 
answers better than the lotion of the same substance. 

Some authorities treat the entire cutaneous surface of the body by 
immersion in various medicated baths for long periods. 

Borax and glycerin (1 : 6) is "the best application for the mouth and 
throat ; and for laryngeal troubles the spray of carbolic acid, mentioned 
upon page 831, answers all purposes. The proportion of cocaine may 
be increased in some cases. 

Many cases of mild, modified smallpox require no treatment but rest 
in bed, a milk diet, a rigid isolation, with the occasional use of warm or 
tepid baths, and inunction with eucalyptus oil. 

VERTIGO— See Tinnitus, page 841, and Ear Diseases, page 218. 

VOMITING. 

The treatment of this symptom is detailed under the various head- 
ings of the different diseased conditions which produce it. (See under 
Dyspepsia, Cancer of Stomach, Gastralgia, Gastric Ulcer, Gastritis, 
Meningitis, Bright's Disease, Intestinal Obstruction, Sea-sickness, Diar- 
rhoea, etc.). 

VOMITING OF PREGNANCY — See under Pregnancy, pages 
695-698. 

WARTS. 

The best treatment for these growths is to apply with a piece of 
match- wood the stongest glacial acetic acid once a day. Where there 



898 WHITLOW OR PARONYCHIA. 

is a very extensive layer of epithelium, the wart should be shaved by 
a razor or a sharp scalpel before applying the acid, and when this is 
carefully done and any bleeding controlled by pressure, one applica- 
tion of the acid may be sufficient. Failure results through want of 
attention to this detail, the horny epithelium shielding the vascular 
tissue from the action of the acid. After the dried crust falls off or is 
removed the acid should be applied until entire destruction is accom- 
plished. Saturated solution of caustic potash or the liquefied drug 
may be applied. It is more speedy and certain than the acid. A less 
painful application is that of salicylic acid in saturated solution in 
collodion. (See page 152.) 

Fowler's solution of arsenic applied daily with a fine camel's-hair 
brush is a reliable wart destroyer, but the writer has found that it pro- 
duces such pain after a time that often its use must be stopped. A 
minute quantity of arsenic made into a paste with water and applied 
to the wart causes its certain destruction. 

Butyr of antimony, nitrate of silver, chromic acid, mercuric nitrate, 
nitric acid, corrosive sublimate, and, nearly every known caustic has 
been recommended, but the glacial acetic acid answers every require- 
ment, even in the most unpromising cases. (See also Condylomata, 
page 135.) 

WENS— See Sebaceous Cysts, page* 777. 
WHITLOW OR PARONYCHIA. 

Whether cutaneous, phlegmonous, periosteal, arthritic, or the result 
of osteomyelitis or tendo-vaginitis, should be strictly regarded as an 
abscess, and treated accordingly, as pointed out by Senn. 

Measures should be directed to cutting short the suppurative pro- 
cess. Occasionally elevation of the part and the prolonged application 
of cold antiseptic solutions or ice succeed in producing the abortion of 
the disease. Where these fail to give relief, and the suppurative 
process is manifestly progressive, aseptic poultices should be applied as 
hot as the patient can tolerate. 

Ordinary poultices of linseed meal, if used, should be smeared over 
with carbolic acid, boric acid, or other antiseptic. By keeping the 
finger immersed in very hot sterilized water relief is often obtained, 
and the progress of matter toward the skin hastened. In all the 
varieties of paronychia, a deep and free incision under antiseptic pre- 
cautions is the only valuable method of treatment. The finger may be 
completely frozen "by the local use of the ether spray, after which an 
incision down to the bone with a stout, sharp scalpel may be made 
without injuring or dividing the extreme finger-tip. The incised digit 
is to be then plunged into cold carbolic lotion until the effect of the 
freezing passes off, after which the liquid is to be heated by the addition 



wounds. 899 

of boiling water until the patient cannot tolerate any further rise of 
the temperature. 

The wound is to be treated upon ordinary surgical principles by 
antiseptic lotions and free drainage. Amputation is very seldom called 
for, the gentle removal of the necrosed bone often being followed by its 
reproduction within the periosteum, providing the incision has not been 
delayed too long, or provided the knife has been carried sufficiently 
deep and free. 

WHOOPING- COUG-H— See under Pertussis. 

WORMS— See Tapeworm, page 822 ; Thread-worm, page 830 ; and 
Ascaris, page 53. 

WOUNDS. 

The surgeon aims at absolute asepsis when he finds it necessary to 
make an incision into the unbroken skin. The various measures for- 
merly considered to be absolutely essential in order to insure asepsis 
are now known to have been unnecessary, and some of them have 
been proved to be injurious. 

The skin having been shaved and well washed with any antiseptic 
solution (the best is corrosive sublimate, I grain to 1 ounce water), the 
wound or incision is made by an instrument rendered sterile by immer- 
sion in carbolic acid solution (4 per cent.), or by boiling in water. The 
operator's hands, and especially his finger-nails, must also be treated by 
carbolic acid or sublimate solution, after careful washing with the nail- 
brush and soap. 

Sponging of the wounded surfaces by ordinary sponges is to be 
avoided. Where these are necessary they must be disinfected after 
repeated washings by prolonged immersion in some antiseptic liquid. 

Pledgets of lint soaked in very weak sublimate solution may be 
made to answer the part of sponges if squeezed dry before being ap- 
plied to the wound. Irrigation of the wound by a stream of sterilized 
water or a warm, weak boric or sublimate solution is often necessary. 

Hemorrhage must be completely arrested by the ordinary surgical 
methods and the most accurate apposition of the wounded surfaces 
effected by suturing, strapping, or bandaging, after providing, where 
necessary, for thorough drainage. Absolute rest to the part and a 
dressing of lint soaked in a weak solution of the previously mentioned 
antiseptics, or of Lister's double cyanide of mercury and zinc, should 
be laid upon the wound and covered with a pad of salicylic, sublimate, 
or iodoform gauze or wool, and kept in position by a bandage exercising 
a very moderate uniform pressure, after which healing by first intention 
may be confidently expected. In the majority of cases, if the above 
precautions have been scrupulously carried out, the dressing need not 
be disturbed for a week, by which time healing may often be found to 
be complete. When, however, pain, increase of tension, and constitu- 



900 WOUNDS. 

tional disturbance, especially the supervention of fever, become 
evident, or when the dressings become saturated with discharge, they 
should be removed, and new ones applied. 

Accidental wounds, whether incised, contused, or lacerated, are to be 
regarded as septic wounds, and the same measures must be employed, 
the chief indication being absolute cleanliness. The wound must be 
thoroughly irrigated by sublimate solution (1 grain to 5 ounces of 
water) ; every recess must be flushed out by this liquid. Suitable 
drainage should then be provided, and, unless in the case of incised 
wounds, sutures must not be used, accurate approximation being effected 
by an arrangement of the dressings by strapping or by bandaging, 
drainage being always necessary. 

Small superficial or lacerated wounds, if rendered thoroughly aseptic 
by carbolic acid or sublimate, may be sealed over with collodion or 
tine, benzoin, comp. ; the former substance upon drying causes such con- 
traction as to firmly hold the margins of the wound together. The 
various lotions suitable for the dressing of open wounds may be seen 
under Abscess, upon page 13. 

So-called poisoned wounds are to be treated upon the same principles 
as already mentioned under septicaemia. In order to effect the most 
complete destruction of the septic substance it may be necessary to 
enlarge the wound before attempting irrigation. A stronger sublimate 
solution (1 : 500) may then be freely applied, or powerful caustics 
may be used under special circumstances, as in post-mortem wounds 
or in bites of rabid animals. (See under Hydrophobia, page 374.) 

Gunshot wounds must be treated upon the same surgical principles 
as ordinary wounds. The seat of injury is to be carefully and patiently 
explored with the finger, and when the projectile is accessible it should 
be removed. For the exploration and extraction it may be often found 
necessary to enlarge the original opening. Various forms of probes 
and bullet-indicators are in use, but when possible the finger is by far 
the best, even if its use necessitates the enlarging of the opening. 

Where the bullet is not easily accessible, there is no doubt that, in 
the majority of cases, its removal should not be attempted. All 
authorities are agreed that its presence will be far less likely to pro- 
duce mischief than prolonged and fruitless attempts at its removal. 
Free irrigation of the wound with antiseptic solutions and the estab- 
lishment of the most complete drainage, if necessary by counter- 
openings, the application of antiseptic dressings, and absolute rest of 
the part and of the patient in bed, with such general treatment as the 
special indications present will suggest, will give far better results 
than repeated attemps at extraction. 

The treatment of the hemorrhage (primary and secondary), of the 
shock, septicaemia, and other results is to be carried out by the use of 
the remedies indicated under their headings. 



YELLOW FEVER. 901 

YELLOW FEVER. 

There is much difficulty in detailing the treatment of a disease which 
varies so remarkably in its severity and termination as yellow fever. 
Those who have had the most experience of its treatment differ strongly 
upon the principles to be carried out in its management. This arises 
from the very marked differences of type observed in different epi- 
demics and in different localities. 

Absolute rest in the horizontal position in bed, with very free ven- 
tilation, is essential in the mildest cases, especially as very mild exam- 
ples of the disease may become malignant at a later stage of their 
course. 

The disease runs a definite course, and, in the absence of any known 
drug exercising a specific action, the object of the physician should be 
to keep the patient alive by careful nursing, judicious feeding, and by 
a rational treatment of the various complications or symptoms which 
by their presence may tend to cut life short. 

Eliminatory treatment in many cases gives good results when com- 
bined with hygienic measures. Diuretics, diaphoretics, and mild 
purgatives may be used from the beginning, and, owing to the con- 
dition of the kidneys, these agents may be demanded. Bloodletting, 
mercurialization, and severe purging are always contra -indicated, 
though recently Sternberg publishes success by small doses of cor- 
rosive sublimate combined with an alkali. The mercurial is, however, 
in too small amount to produce constitutional symptoms. The follow- 
ing is his formula, very slightly modified : 

Be. — Sodii bicarb. . . gr. vij. 

Hydrarg. chlor. corros gr. ^. 

Aquae dest ^ij. — M. 

S. — To be taken iced every hour. 

With this treatment he affirms that he has reduced the mortality 
from 30 to 6.5 per cent., and he is satisfied that the alkali will give 
the best of all results. His object in using it is to render alkaline the 
highly acid urine. It prevents suppression of urine and hsematemesis, 
the bichloride being added simply with the view of preventing fer- 
mentative changes in the stomach. 

Mitchell reports highly of this method of treatment. He increases 
the strength of the mixture, using the following proportions : 

R. — Sodii bicarb. gr. xijss. 

Hydrarg. chlor. corros. gr. ^. 

Aquae dest ^ij. — M. 

S. — To be taken every hour. 

This would represent, if given hourly, rather more than 1 grain of 
corrosive sublimate every forty-eight hours, and it is obvious that such 
treatment could not be safely continued for many days. 



902 YELLOW FEVER. 

Hyperpyrexia, as in other fevers, must be met by the cold or tepid 
bath, and high temperature falling short of hyperpyrexia should be 
reduced by cold sponging of the surface of the body. 

Quinine, as a rule, is disappointing, unless malarial influences are 
also present. There is as yet no evidence known to the writer in favor 
of the new antipyretics. 

The gastric disturbance generally present calls for very active 
measures, and it is claimed for the corrosive sublimate and sodium 
treatment that, if commenced early, it tends to keep this symptom in 
abeyance. Blisters or sinapisms to the stomach region, ice internally, 
with small doses of bismuth or prussic acid, may be tried. Flint 
restricted the diet to milk and lime-water. Stimulants are indicated 
in the majority of cases, and champagne may be freely given. Life 
has often been saved by the rectal administration of brandy and whis- 
key. The injection of large quantities of normal saline solution may 
be indicated, and, from theoretical considerations, in desperate cases 
the writer would recommend the intravenous injection of 2 to 4 pints 
of the following solution : 

R. — Sodii chlor . gij. 

Sodii bicarb. 5 v. 

Aquse dest Oiv. — M. 

S. — The liquid for intravenous injection. 

Freire's method of inoculating has given excellent results, and, 
though condemned by several, the reports appear to establish its most 
decidedly successful prophylactic action. 



INDEX. 



A BDOMINAL hemorrhage, 496 
J\. inflammation, 243 

neuralgia, 522 

obstruction, 416 

section, 420, 507, 613 

taxis, 418 
Abernethy's lotion, 553 
Abortion, 9 

causing endometritis, 243 
Abscess, 12 

cerebral, 332 

chronic, 13 

cold, 13 

hepatic, 451 

joint, 15, 428, 431 

mammary, 12, 485 
chronic, 486 

of cornea, 150 

of kidney, 736 

of liver, 451 

of meatus externus, 219 

pelvic, 591 

perityphlitic, 614 

phlebitic, 632 

psoas, 714 

submammary, 485 

tonsillar, 833 

tubercular, 15 
Absent menstruation, 33 
Accommodation, spasms of, 56 
Acid bath, 454 

dyspepsia, 217 

hydrocyanic, poisoning by, 682 

prussic, poisoning by, 682 
Acidity, 15, 217 

Acids, mineral, poisoning by, 682 
Acne, 17 

rosacea, 20 
Aconite, poisoning by, 782 
Acromegaly, 22 
Actinomycosis, 22 
Acupuncture, 463 

and opiate treatment, 523 
Addison's disease, 22 



Adhesion of eyelid to eyeball, 808 
Ague, 414 
Air (hot) baths, 73 
Albuminuria, 23 

of Bright' s disease, 77 

of delirium tremens, 171 

of pregnancy, 24 
Albuminuric retinitis, 742 
Alcohol in alcoholism, 26 

in delirium tremens, 168 

in fevers, 869 

in insomnia, 404 

in phthisis, 640 

in pneumonia, 676 

in strychnine poisoning, 691 
Alcoholic amblyopia, 29 

paralysis, 585 

poisoning, 24, 683 
Alcoholism, 24 
Alkalies, poisoning by, 683 
Alkaline treatment of rheumatism, 750 
Alkalinity of urine, 635 
Almond bread (Purdy's), 177 
Alopecia areata, 64 
Amaurosis, 28 
Amblyopia, 29 
Amenorrhoea, 30 
Amenorrhoeic constipation, 145 
Ammonia, poisoning by, 683 
Amputation of cervix uteri, 108 
Amyloid kidney, 79 

liver, 452 
Anaemia, acute, 36 

chronic, 38 

in Bright' s disease, 79 

pernicious, 40 

simple, 39 
Anaemic amenorrhoea, 33 

constipation, 38 

headache, 330 

neuralgia, 39, 521 
Anaesthetics, administration of, 685 

in intestinal obstruction, 420 
Anasarca, 77 



904 



INDEX 



Aneurism, 41 
Angeioleucitis, 481 
Angina pectoris, 43 
Anteflexion of uterus, 890 
Antero-posterior curvature, 113 
Ante version of uterus, 890 
Antidote, general, 682 
Antimony, poisoning by, 683 
Antrophores, 292 
Anuria, 804 
Anus, fissure of, 46 

fistula of, 47 

imperforate, 50 

prolapse of, 699 

pruritus of, 49 

ulcer of, 46 
Aortic obstruction, 347 

regurgitation (pure), 347 

with mitral regurgitation, 346 

stenosis, 347 
Aphasia, 50 
Aphonia, 50 

in hysteria, 51, 388 
Aphthse, 51 

Aphthous stomatitis, 51 
Apoplexy, 51 

Apostolus electrical method, 505 
Appendicitis, 612 
Aquapuncture, 463 
Arachnitis, 502 
Arsenical poisoning, 683 

treatment of chorea, 124 
of eczema, 225 
Arterial hemorrhage, 314 

tension in Bright's disease, 79 
Arthrectomy, 428, 431 
Arthritic haemoptysis, 312 
Arthritis, rheumatic, 743 
Arthrotomy, 430 
Articular ostitis, 427 
Artificial palate, 128 

purulent ophthalmia, 137 

respiration (Hall's), 200 
(Howard's), 201 
(Sylvester's), 201 
Ascaris lumbricoides, 53 

mystax, 53 
Ascites, 53 

in cirrhosis, 452 
Aspiration, 236 

of hernia, 359 

of hydronephrosis, 373 

of ovarian cyst, 566 

of pericardium, 598 

of pleuritic effusion, 669 
Asthenopia, 55 
Astigmatism, 56 



Asthma, 56 

cardiac, 61 
Astringent injections, list of, 449 

lotions for conjunctivitis, 135 
Athetosis, 61 

Atmospheres, medicated, 654 
Atonic dyspepsia, 214 
Atresic amenorrhoea, 31 
Atrophic paralysis, acute, 583 
Atrophy of liver, 452 

of optic nerve, 28 
Atropine poisoning, 684 
Aura in epilepsy, 252 . 
Aural exostosis, 219 
Auricle, hematoma of, 218 
Avulsion of nerve, 535 



BALANITIS, 62 
Baldness, 63 
Banting's dietary, 545 
Barking cough of puberty, 155 
Bath, acid, 454 

hot air, 73 

poor man's, 73 

static (electric), 388 
Baths in Bright's disease, 74 

in typhoid, 867 
Bedsores, 65 

in myelitis, 514 

in typhoid, 875 
Bee stings, 785 
Belladonna poisoning, 684 
Bell's paralysis, 586 
Bile-duct, obstruction of, 270 
Biliarv calculi, 268 

colic, 268 
Bird's treatment of bedsores, 66 
Black eye, 93 
Bladder, atony or atrophy of, 70 

cancer of, 99 

inflammation of, acute, 66 
chronic, 67 

prolapse of, 702 

stone in, 790 
Blebbed chilblains, 120 
Blepharitis, 70 
Blindness, 28 

in glaucoma, 280 
Bloodletting, 498, 500 
Bloody sweating, 302 
Boils, 70 

Bone diseases, 111, 601, 779 
Bony growths in ear, 218 
Bothriocephalus, 823 
Bouchardat's diabetic dietary, 184 
Bougies, oesophageal, 552 



INDEX 



905 



Bougies, urethral, 281, 796 

Bowel, hemorrhage from, 496 
inflammation of, 244 

obstruction of, 41(5 

perforation of, 276, 610, 875 

stricture of, 416 
Bow-leg, 278 
Brain fever, 487 

hydatids, 370 

symptoms in head injuries, 332 
Braithwaite's cancer treatment, 107 
Bran bread, 176 

Brand's treatment of fevers, 867 
Bread, diabetic, 177 
Breast, abscess of, 12, 485 

cancer of, 99 

inflammation of, 485 
Breathlessness, 234 

cardiac, 338 
Bright' s disease, acute, 72 

chronic, 75 
Brocq's solution, 591 
Bromidrosis, 80, 616 
Bronchial asthma, 57 

cough, 153 

inflammation in heart disease, 353 
Bronchiectasis, 81 
Bronchitis, acute, 82 

chronic, 87 
Bronchorrhoea, 91 
Bruises, 93 
Bubo, 93 

Bulau's treatment of empyema, 236 
Bunion, 94 

Burnett's fluid, poisoning by, 692 
Burns, 95 
Bursitis, 98 
Buttermilk in diabetes, 179 



pALABAR-BEAX poisoning, 688 
\J Calculi, biliary, 268 

pancreatic, 578 

renal, 787 

urethral, 794 

vesical, 790 
Callosities, 152 
Camphor, poisoning by, 684 
Cancer, 98 

epithelial, 763 

excision of, 99 

of bladder, 99 

of breast, 99 

of colon, 105 

of gullet, 101 

of intestines, 104 

of liver, 105, 455 



Cancer of pylorus, 104 

of rectum, 105 

of stomach, 102 

of tongue, 101 

of uterus, 106 
Cancerous ulcer, 100 
Cancrum oris, 109 
Cannabis indica poisoning, 684 
Cantani's diabetic dietary, 184 
Cantharides poisoning, 684 
Cantharidinate of potassium, treatment 

of tubercle by, 857 
Capillary hemorrhage, 314 
Carbolic acid poisoning, 684 
Carbuncle, 110 
Carcinoma, 98, 763 

of nipple, 542 
Cardiac asthma, 67 

breathlessness, 338 

complications of rheumatism, 747 

dropsv, 352 

failure, 353 _ 

in delirium tremens, 170 
in erysipelas, 256 
in pneumonia, 676 

neuralgia, 529 

pain, 353 
Caries, 111 

of spine, 113, 779 
Carious oz?ena, 577 
Carron oil, 96 
Catalepsy, 115 
Cataract, 116 
| Catarrh, 82, 118 

gastric, 276 

of ear, 220 
Catarrhal conjunctivitis, 135 

dyspepsia, 214 

jaundice, 423 

pharyngitis, 626 

sore-throat, 154 

stomatitis, 785 
Catheter, double-barrelled, 506 
Catheterism, tracheal, 197 
Catheterization, 67, 741 

after ovariotomy, 571 
Caustic poisoning, 691 
Cellulitis, pelvic, 591 
Cellulo-cutaneous ervsipelas, 259 
Cephalalgia, 330 
Cerebral arteries, disease of, 52 

cough, 154 

meningitis, 497 
Cerebro-spinal fever, 500 
meningitis, 500 
Cervical caries, 115 

endometritis, 244 
i8 • 



906 



INDEX. 



Chancre, 810 

Chapped hands, 119 

Chilblains, 119 

Chloasma, 121 

Chloral hydrate poisoning, 684 

Chlorate of potassium poisoning, 691 

Chlorine poisoning, 685 

Chloroform, administration of, 685 

poisoning, 685 
Chlorosis, 121 
Cholecystotomy, 270 
Cholera Asiatica, 122 

infantum, 187 
Chordee, 289 
Chorea, 123 
Choroiditis, 12 1 ) 
Chyluria, 127 
Circumcision, 631 
Cirrhosis of liver, 452 
Cirrhotic Bright's disease, 79 
Cleft palate, 128 

Clergyman's sore-throat, 367, 438 
Climatic treatment of asthma, 56 

of phthisis, 642 
Club-foot, 129 
Coccydynia, 130 
Cod-liver oil inunction, 507 
Colchicum in gout, 294 

poisoning, 687 
Cold applications to scalp, 497 
Colic, biliarv, 268 

hepaticj 268, 423 

intestinal, 131 

lead, 132 

painter's, 673 

renal, 787 
Collapse, 133 

from hemorrhage, 313 

in cholera, 122 

in periostitis, 605 

of lung, 87 
Coma, 134 

hysterical, 387 

in alcoholism, 24 

in diabetes, 181 

in meningitis, 498 
Compound fractures, 267 
Compressed-air treatment, 234 
Concussion, 134, 331 
Condylomata, 135 
Congestion of conjunctiva, 138 

of liver, 455 

of lung, 353 

of stomach, 302 
Congestive dysmenorrhoea, 208 

dyspepsia, 214 

headache, 330 



Conium ointment, 47 

poisoning by, 687 
Conjunctivitis, 135 

diphtheritic, 138 

granular, 138 
Constipation, 139 

amenorrhoeic, 33 

ansemic, 39 

in children, 147 

in typhoid, 874 
Continuous headache, 494 
Contraction of palmar fascia, 202 
Contused wounds, 900 * 
Convulsions, 148 

hysterical, 386 

in dentition, 173 

infantile, 149 

in measles, 491 

puerperal, 722 

uraemic, 78 
Copper salts, poisoning by, 687 
Cornea, inflammation of, 150 
Corneal ulcer, 139, 151 
Corns, 152 

Corrosive sublimate poisoning, 690 
Coryza, 82, 118 
Cough, 153 

dental, 154 

dry, 88 

ear, 154 

hepatic, 154 

of measles, 490 

of phthisis, 655 

pleuritic, 670 

whooping-, 617 
Crab lice, 590 
Cramp, 155 

Creasote poisoning, 684, 688 
Cretinism, 155 
Crico-tracheotomy, 164 
Croton oil poisoning, 688 
Croup, 155 

spasmodic, 437 
Croupous ophthalmia, 138 
Crowing, 437 
Curetting, 108, 243. 
Curvature, spinal, 113, 779 
Cutaneous ulcer, 879 
Cyanide of potassium, poisoning by, 688 
Cystic goitre. 2S5 
Cystitis, 66 
Cysts, pancreatic, 578 

sebaceous, 777 

DAXDKUFF, 166 
Danvpe's bread, 178 
Debility, 166 



INDEX. 



907 



Delirious mania, 487 
Delirium, 167 

of typhoid, 873 

tremens,* 167 
Dementia, 171 
Dengue, 172 
Dental cough, 154 

neuralgia, 525 
Dentition, disorders of, 173 
Depressed nipple, 539 
Depression in opium habit, 556 
Dermatitis, exfoliative, 660 
Diabetes, 175 

insipidus, 174, 694 
Diachylon ointment, 81, 616 
Diarrhoea, 186 

alcoholic, 190 

chronic, 189 

from scybala?, 148 

in Bright' s disease, 78 

inflammatory, 187 

irritative, 186 

lienteric, 190 

malarial, 190 

nervQus, 190 

of cholera, 123 

of jaundice, 426 

of phthisis, 658 

of typhoid fever, 873 

simple, 187 

summer, 187 
Diet in diabetes, 176 
Dietaries in diabetes, 182 

in fatty heart, 343 
Dietary in obesity, 545 

in typhoid, 861 
Digitalis in heart disease, 346 

poisoning, 687 
Dilatation of cervix uteri, 205 

(continuous) of urethra, 791 

(forcible) of urethra, 798 

in phimosis, 630 

of heart, 333 

of oesophagus, 551 

of urethra, 795 
Dimness of vision, 29 
Dinner pills, 144, 145 
Diphtheria, 191 

bacillus, 194 
Diphtheritic conjunctivitis, 138 

paralysis, 580, 198^ 

nature of croup, 157 
Dislocations, 198 
Disseminated sclerosis, 772 
Divulsion of stricture, 798 
Dog's serum for tuberculosis, 851 
Dropsy, 199 



Dropsy, cardiac, 352 

of pericardium, 598 
purulent, 599 

ren.al, 77 
Drowning, 199 
Dry cough, 88 
Dry cure of obesity, 548 
Dry pleurisy, 671 

Dupuvtren's contraction of palmar fas- 
cia/ 202 
Dysentery, 202 
Dysidrosis, 204 
Dysmenorrhea, 204 

congestive, 208 

inflammatory, 208 

membranous, 208 

neuralgic, 205 

ovarian, 209 

spasmodic, 205 
Dyspepsia, acute, 210 

atonic, 214 

chronic, 211 

in alcoholism, 27 

irritative, 213 
Dyspnoea, bronchitic, 83 

cardiac, 353 

emphysematous, 234 

of endocarditis, 240 

of false croup, 156, 161 

pulmonary, 674 

ursemic, 78 



PAR, abscess of, 219 
Jj bonv growths in, 218 

catarrh of, 220 

cough, 154 

diseases of, 218, 561 

eczema, 218 

exostoses, 218 

foreign bodies in, 219 

fungi, 219 

heematoma, 218 

internal, 222 

middle, 220 

purulent catarrh of, 221 

polypi in, 222 

ringing in, 222, 842 

wax in, 219 
Ebstein's diabetic dietary, 184 

treatment of obesity, 545 
Ecchymosis, 93 
Eclampsia, 723 
Ecthyma, 222 
Ectopia vesica, 253 
Ectropion, 244 
Ectrotic treatment, 258 



908 



INDEX 



Eczema, 223 

acute, 226 

chronic, 228 

of ear, 218 

of nipple, 542 
Eczematous dandruff, 166 

ulcer, 886 
Effusion in cerebro-spinal meningitis, 
501 

in meningitis, 499 

in pleurisy, 666 
Elaterium poisoning, 688 
Electric souffle, 388 

treatment of hysteria, 388 
of locomotor ataxia, 457 
Electricity, Apostolus method, 505 

in paralysis, 585 
Elephantiasis, 232 
Emetics, 681 

in bronchitis, 85 

in croup, 156 

in poisoning, 680 
Emmenagogues, 30 

list of, 34 
Emphysema (general), 235 

of the lung, 233 
Empyema, 235 
Endocarditis, 239 

ulcerative, 241 
Endometritis, 241, 508 
Enemata, 140, 148, 341, 342 

peptonized, 274, 646 
Enlarged bursa, 98 

prostate, 706 

tonsils, 834 
Enterectomy, 104 
Enteric fever, 860 
Enteritis, 244 

in diarrhoea, 187 
Enterotomy, 104 
Entropion, 244 
Enuresis, 394 
Ephelides, 121 
Epididymitis, 557 

following gonorrhoea, 558 
Epilation, 805 
Epilepsy, 246 
> focal, 253 
Epiphora, 253 
Episcleritis, 772 
Epispadias, 253 
Epistaxis, 253 
Epithelial cancer, 101, 763 
Epithelioma, 763 
Epsom salt treatment (Hay's), 77 
Epulis, 255 
Erysipelas, 255 



Erysipelas of face, 259 
Erythema, 259 

pernio, 119 
Erythematous tonsillitis, 833 
Eserine poisoning, 688 
Estlander's operation, 238 
Ether poisoning, 688 
Exanthemata, 489, 767, 859, 876, 888 
Excessive perspiration, 615 
Excision of cancer, 99 

of fistula, 48 

of hernial sac, 361 

of joints, 366, 432 

of lupus, 477 

of nerve, 535 
Exercise in cardiac disease, 342 

in obesity, 544 
Exfoliative dermatitis, 660 
Expectoration from gangrenous lung, 
464 

purulent, 89 
Exostosis, 261 

aural, 219 
Exophthalmic goitre, 287 
Extension in hip disease, 364 
Extra-uterine foetation 262 
Exudation in cerebro-spinal meningitis. 
501 _ 

in meningitis, 499 
Eyelid, adhesion of, to eyeball, 808 

eversion of, 244 

inversion of, 244 



FACIAL neuralgia, 525 
paralysis, 586 
Failing compensation of heart, 341 
Fallopian tubes, inflammation of, 737 
False croup, 156 
Famine fever, 739 
Fatty growth on heart, 338 

heart, 336 

infiltration of heart, 338 

kidney, 79 
Favus, 263 
Febricula, 264 
Fecal accumulation, 141 
Femoral hernia, 357 
Fenwick's treatment of pyrexia, 675 
Ferrier's snuff, 118 
Fever, 265 

after ovariotomy, 572 

brain, 487 

cerebro-spinal, 500 

famine, 739 

hay, 326 

hectic, 354 



INDEX. 



9Q9 



Fever, intermittent, 418 

of phthisis, 645, 656 

puerperal, 725 

relapsing, 789 

remittent, 740 

rheumatic, 747 

scarlet, 767 

typhoid, S60 

tvphus, 876 

yellow, 901 
Fibro-cystic goitre, 285 
Fissure of anus, 46 
Fissured nipple, 541 
Fistula of anus, 47 

perineal, 886 

urinary, 886 
Fixation of uterus, 705 
Flap operation for cataract, 117 
Flatulence, 218 
Flexions of uterus, 243, 888 
Flying blisters, 666 
Foliaceous pemphigus, 595 
Follicular pharyngitis, 627 

stomatitis, 785 

tonsillitis, 831 
Forcible flexion in ataxia, 461 
Foreign bodies in ear, 219 

in oesophagus, 550 

in intestine, 421 
Fracture of base of skull, 333 

causing meningitis, 500 
Fractures, 265 
Freckles, 121 
Frost-bite, 266 
Fumigation of ulcers, 883 
Functional disease of heart, 333 
Fungi in ear, 219 

poisoning, 688 
Furunculus, 71 



GALACTOCELE, 486 
Gall-stone, 268 < 

obstructing intestine, 419, 421 
Galvano-puncture, 42 
Ganglion, 270 
Gangrene, 271 

from frost-bite, 267 

hospital, 272 

of lung, 264 

of vermiform appendix, 613 

senile, 271 

spontaneous, 739 

traumatic, 271 
Gangrenous hernia, 359 
Gastralgia, 272 



j Gastric catarrh, 276 
Gastric hemorrhage, 301 

ulcer, 273 

chronic, 276 
Gastritis, 277 

from alcoholism, 24 
<i;istro-enterostomy, 104 
Gastrotomy, 102 
Gelsemium poisoning, 689 
General paralysis of the insane, 584 
Genitals, malformation of, 31 
Genu extrorsum, 278 

valgum, 278 
German measles, 764 
Germain-See's diabetic dietary, 184 
treatment of obesity, 547 
Giddiness, 841 
Glanders 278 

Glands, diseases of, 477, 507, 773 
< Glaucoma, 279 
Gleet, 280 
Glossitis, 283 
Gluten bread, 178 
Glycerinum saponatum, 231 
Glycosuria, 175 
Goat's-blood treatment of tubercle, 

857 
' Goitre, 283 

cystic, 285 

exophthalmic, 287 
[ Gonorrhoea, 288 

in women, 293 
Gonorrhceal rheumatism, 757 

balanitis, 62 

cystitis, 66 
Gouging, 112 
J Gout, 293 
: Gouty bronchitis, 84 

cystitis, 67 

headache, 331 

orchitis, 559, 560 

synovitis, 809 
Grafting, sponge and skin, 882 
Granular cervix, 243, 888 

conjunctivitis, 138 

lids, 150 

ophthalmia, 138 

pharyngitis, 627 
Grattage/628 
Gravel, 787, 790 
Grave's disease, 287 
Gray oil, 816 
Gullet, cancer of, 101 

stricture of, 102, 552 
| Gum bread, 178 
Gums, spongy, 787 
Gunshot wounds, 900 



910 



INDEX 



HJEMATEMESIS, 301 
Haematidrosis, 302 
Hematinuria, 303 
Hematocele, 303 

pelvic, 303 

scrotal, 303 
Hematoma, 306 

of auricle, 218, 306 
Hematuria, 306 
Hemoglobinuria, 303 
Haemophilia, 308 
Hemoptysis, 309 

in phthisis, 658 
Haemorrhoids, 318 
Hemothorax, 324 
Hall's artificial respiration, 201 
Hard cataracts, 11.7 
Hare-lip, 325 
Hay fever, 326 

Hay's treatment of dropsy, 77 
Hazard's solution, 761 
Headache, 330, 492 

after iron, 40 

in Bright's disease, 79 

in meningitis, 497 

in tubercular meningitis, 502 

in typhoid, 873 
Head injuries, 331 
Heartburn, 210 
Heart, dilatation of, 333 

diseases of, 333 

fatty degeneration of, 336 
growth on, 33S 

functional diseases of, 334 

hypertrophy of, 338 

rapid, 336 

valvular disease of, 334 
Hebra's diachylon ointment 81, 616 

paste, 73, 476 
Hectic fever, 354 
Hellebore poisoning, 682 
Hemicrania, 492 
Hemiplegia, 355 
Hemorrhage, 313 

from the bowels, 496 

from the lung, 310 

from the stomach, 273, 301 

from uterus, 107, 316, 504, 662 

gastric, 301 

in cancer, 101 

in mole pregnancy, 510 

in placenta previa, 662 

in typhoid, 874 

post-partum, 315 

renal, 78, 789 

urethral, 800 

with collapse, 134 



Hemorrhagic phthisis, 643 

purpura, 731 

smallpox, 896 
Hepatic cough, 154 

diseases, 451 
Hepatitis, 455 
Hepatotomy, 451 
Hernia, 356 

aspiration of, 359 

excision of sac, 361 

femoral, 357 

gangrenous, 361 

inflamed, 361 

internal, 416 

irriducible, 357, 362 

manipulation of, 358 

omental, 361 

operation for, 359 

perforating, 361 

radicle cure of, 361 

recent, 356 
, reduction of, 358 

strangulated, 357 

taxis for, 358 

umbilical, 357 
Herniotomy, 360 
Herpes, 362 

circinata, 835 
Hiccough, 363 

Hilton's treatment of abscess, 13 
Hip-joint disease, 364 
Hives, 259 
Hoarseness, 367, 438 
Hodgkin's disease, 480 
Hospital gangrene, 272 

sore-throat, 831 
Hot air baths, 73 

pack, 73 
Housemaid's knee, 98 
Howard's artificial respiration, 201 
Hydatids, 367 

of brain. 370 

of liver, 368 

of lung, 369 

of pleura, 369 

suppurating, 369 
Hyderabad Commission Keport, 6S5 
Hydrocele, 370 

congenital, 372 

encysted, 372 

in orchitis, 559 

radical cure of, 370 

tapping, 370 
Hydrocephalus, acute, 499 

chronic, 372 
Hydrocyanic acid poisoning, 682 
Hydronephrosis, 373 



NDEX. 



911 



Hydropathy in fever, 867 
Hydropericardium, 598 
Hydrophobia, 474 
Hydrops articuli, 810 
Hydrothorax 380 
Hygienic treatment of phthisis, 641 
Hyoscyamus poisoning, 684, 688 
Hypersesthesia, 536 
Hyperidrosis, 615 
Hypermetropia, 380 
Hyperpyrexia, 753, s 67 
Hypertrophy of heart, 338 

of prostate, 706 

of tongue, 843 

of tonsils, 834 
Hypnotics in delirium tremens, l'>8 

versus narcotics, 404 
Hypnotization, 536 
Hypochondriasis, 380 
Hypopyon, 151 
Hypospadias, 382 
Hysterectomy, 10S 
Hysteria, 382 
Hysterical aphonia, 51, 338 

coma, 387 

convulsions, 386 

neuralgia, 528 

paralysis, 388 
Hystero-epilepsy, 3S9 



ICHTHYOSIS, 390 

of tongue, 844 
Icterus, 423 
Impetigo, 391 
Impotence, 391 
Incised wound, 900 
Incontinence of urine, 393 
Indian treatment of goitre, 284 
Indolent ulcer, 881 
Indurated orchitis. 559 
Infantile colic, 131 

convulsions, 149 

jaundice, 426 

leucorrhoea, 449 

ophthalmia, 136 

paralysis, 583 

tetanus, 829 
Inflamed hernia, 361 

piles, 320 

ulcer, 884 
Inflammation of bladder, 66 

of bowels, 244 

of bronchi, 80, 353 

of liver, 455 

of lung, 673 



I nl! animation of meatus externus, 219 

of ovaries. 562 

of pleura, 063 

of prostate, 705 

of rectum, 698 

of testicle, 557 

of tongue, 283 

of uterus, 241 

of vermiform appendix, 612 
Inflammatory diarrhoea, 188 

dysrnenorrhcea, 208 

laryngitis, 157 
Inflation of bowel, 419 
Influenza, 397 
Ingrowing toe-nails, 398 
Injections of blood, 37 

leucorrhoeal, 449 

of saline solutions, 37 

of gases, 649 

urethral, 292 

vesica], 68 
Insanity, 400 
Insolation, 803 
Insomnia, 401 
Intercostal neuralgia, 533 
Intensive treatment of rabies, 379 
Intermediate svmptoms of syphilis, 

818 
Intermittent fever, 413 
Intertrigo, 415 
Intestinal colic, 132 

hemorrhage, 496 

inflammation, 244 

obstruction, 415 
chronic, 421 

perforation, 276, 610 

stricture, 416 
Intubation of oesophagus, o^) 
Intubation of trachea, 197 
Intussusception, 419 
Inunction, mercurial, 814 

of cod-liver oil, 507 
Inversion of uterus, 891 
Iodine poisoning, 689 
Iridectomy, 27') 
Irido-choroiditis, 423 
Iritis, 422 

Irreducible hernia, 357, 362 
Irrigation, 118 

treatment of diarrhoea, 189 
Irritable ulcer, 884 
Irritative diarrhoea, 186 

dyspepsia, 213 
Itch, 765 

Itching in measles, 491 
of anus, 49 
of erythema, 259 



912 



INDEX 



TAUNDICE, 423 
t) catarrhal, 426 

infantile, 426 

simple, 424 
Jaw, necrosis of, 520 
Joint abscess, 15, 428, 430 

diseases, 364, 426, 429, 765 

inflammation of, 809 



KELOID, 429 
Keratitis, 151 
Keratosis of tongue, 844 
Kidney, abscess of, 636 
amvloid, 79 
cirrhosis, 79 
diseases, 72, 512, 736 
fatty, 79 
movable, 512 
Knee-joint disease, 429 

excision of, 432 
Knock-knee, 278 
Koch's syringe, 852 

treatment of lupus, 470, 852 
of tuberculosis, 850 
of tuberculous bones and joints, 
853 
Koumiss, 23, 637 



LABILE galvanization, 585 
Labor, 433 
Laburnum poisoning, 689 
Lacerated wound, 900 
Lamellar cataracts, 116 
Landry's paralysis, 513 
Lannelongue's treatment of tubercle, 858 
Laparotomy, 420 
Laryngeal spasm, 437 
Laryngismus stridulus, 447 
Laryngitis, 437 

acute, 437 

chronic, 438 

rheumatic, 439 

spasmodic, 155 

stridulus, 155 

syphilitic, 442 

tubercular, 439 
Laryngo-tracheotomy, 164 
Larynx, oedema of, 442 
Lassar's paste, 228 
Lateral curvature, 779 

lithotomy, 792 
Lead colic, 132 

paralysis, 672 

poisoning, 689 

amblyopia of, 30 



Lead poisoning, chronic, 672 

Lentigo, 120 

Le Peine's treatment of tubercle, 856 

Leprosy, 443 

Leprous ulcers, 444 

Leptomeningitis, 502 

Leucoderma, 444 

Leucocythsemia, 445 

Leucoplakia, 844 

Leucorrhcea, 241, 446 

infantile, 449 
Leucorrhoeal injections, 449 
Leukaemia, splenic, 445 
Lewsaschew's treatment of pleurisy, 670 
Lice, 589 
Lichen, 449 
Lids, granular, 150 
Liebreich's treatment of tubercle, 857 
Lienteric diarrhoea, 190 
Lightning injuries, 450 
Lime poisoning, 689 
Linear extraction of cataract, 116 
Lithiasis, 787 
Litholapaxy, 790 
Lithotomy, 792 
Lithotrity, 791 
Liver, abscess of, 451 

amyloid, 452 

atrophy of, 452 

cancer of, 105, 455 

cirrhosis of, 452 

colic, 268, 423 

congestion of, 455 

excision of, 105 

hydatids of, 368 

inflammation of, 455 

injuries to, 455 

rupture of, 455 

syphilitic disease of, 456 
Lobelia poisoning, 690 
Local paralysis, 585 
Lock-jaw, 827 
Locomotor ataxia, 456 
London paste, 473 
Lumbago, 461 
Lumbricoides, 54 
Lung, abscess of, 463 

collapse of, 87 

congestion of, 353 

emphysema of, 233 

gangrene of, 464 

hemorrhage, 310 

hydatids, 369 

inflammation of, 673 

oedema of, 78, 466 

softening of, 640 

wounds of, 466 



INDEX. 



913 



Lupus erythematosus, 467 
vulgaris, 469 

Lymphadenitis, 477 

purulent, 479 
Lymphadenoma, 480 

non-leukaemic, 481 
Lymphangitis, 481 

with lymphadenitis, 477 
Lymphatic glands, hypertrophy of, 480 
inflammation of, 477 
tuberculous, 773 



MACROGLOSSIA, 843 
Malaria, 413 

Malarial diarrhoea, 190 

dysentery, 202 

neuralgia. 524 

orchitis, 561 
Malignant disease, 98 

disease of nipple, 542 

stricture of oesophagus, 102, 551 

pustule, 482 
Mammary abscess, 12, 482 

cancer, 102 

inflammation, 482 
Mania, 487 

puerperal, 729 • 

Martin's bandage, 879 
Mastitis, 482 
Mastoiditis, 222 
Mastoid swelling, 221 
Masturbation, 487 
McKeown's irrigation, 117 
Measles, 489 

German, 764 
Meatus, foreign bodies in, 219 

inflammation of, 219 
Median lithotomy, 793 
Megrim, 492 

Meigs's milk and cream food, 187 
Melama, 496 
Melancholia, 400 
Melon seed bodies, 98 
Membrani tympani, perforation of, 221 
Membranous dysmenorrhoea, 203 
Meniere's disease, 222, 842 
Meningitis, cerebral (simple), 497 

cerebro-spinal, 500 

spinal, 501 

tubercular, 502 
Menorrhagia, 242, 504 
Menstruation, absent, 31 

delaved, 31 

disorders of, 31, 204, 504 

obstructed, 204 

profuse, 504 



Menstruation, suppressed, 33 
Mercurial poisoning, 690 

stomatitis, 787 
Mesenteric gland disease, 507 
Metritis, 508 
Metrorrhagia, 504 

Microorganism theory of anaemia, 41 
Micturition, incontinent, 393 

retained, 741 

suppressed, 804 
Middle ear, catarrh of, 220 

diseases of, 220 

purulent catarrh of, 221 
Migraine, 492 
Milk and cream food (Meigs's), 187 

cure for phthisis, 637 

cysts, 486 

treatment of diabetes, 178 
of heart disease, 344 
of obesity, 547 
Mineral acid poisoning, 682 
Miscarriage, 9 
Mitral obstruction, 347 

regurgitation, 346 

stenosis, 347 
Mole pregnancy, 510 
Moles, 510 

Mollities ossium, 511 
Molluscum contagiosum, 511 

fibrosum, 512 
Moral treatment, 381, 383 
Morbilli, 489 
Morning sickness, 695 
Morphine habit, 554 

poisoning, 690 

vaseline, 100 
Mosquito bites, 785 
Movable hydatids, 368 

kidney, 512 
Mucous patches, 135 

tubercles, 135 
Mumps, 512 

Muscarin poisoning, 688 
Muscular atrophy, paralysis from, 587 

rheumatism, 758 
Mushroom poisoning, 689, 690 
Myalgia, 758 
Myelitis, 513 
Myoma, uterine, 506 
Myopia, 514 
Myxoedema, 515 



V .EVUS, 516 
1 1 Nail, avulsion of, 554 
Xails, inflammation of matrix of, »)54 
ingrowing, 397 



914 



INDEX. 



Narcotics in delirium tremens, 169 

versus hypnotics, 404 
Nasal catarrh, 118 

douches, 575 

duct, stricture of, 253 

polypi, 692 

in asthma, 57 
Nausea, 210 
Necrosis, 520 

Needle operation for cataract, 116 
Nephrectomy, 374 
Nephritic colic, 787 
Nephritis, 72 
Nephrolithiasis, 787 
Nephrotomy, 374 
Nerve avulsion, 535 

excision of, 535 

grafting, 536 

section, 5.35 

stretching, 535 
Nervous diarrhoea, 190 
Nettle rash, 259 
Neuralgia, 521 

abdominal, 522 

ansemic, 521 

cardiac, 529 

dental, 526 

facial, 526 

hysterical, 528 

in herpes, 362 

intercostal, 533 

in lead poisoning, 522 

malarial, 524 

nocturnal, 530 

of tongue, 843 

ovarian, 530 

su ( ra-orbital, 524 

uterine, 522 

visceral, 525 
Neuralgic dysmenorrhoea, 205 

remedies, internal, 523 
external, 530 
Neurasthenia, 383 
Neuritis, 536 
Neuroma, 537 
Neurotic hay fever, 327 
Neurectomy, 534 
Neurotomy, 534 
Nitrites, administration of, 44 
Nightmare, 537 
Night sweats, 659 

terrors, 538 
Nipple, carcinoma of, 543 

depressed, 539 

eczema of, 542 

fissured, 541 

malignant disease of, 542 



Nipple, Paget's, 542 

sore, 539 

ulcerated, 541 
Nitrate of silver poisoning, 691 
Nitric acid poisoning, 682 
Nits, 590 
Nocturnal emissions, 488, 778 

neuralgia, 530 
Nodes, 603, 819 

Non-leuksemic lymphadenoma, 480 
Nose, affections of, 575, 692 
Nutrient suppositories, 2.74 
Nux vomica poisoning, 690, 691 
Nymphomania, 542 



ABESITY, 543 
' / Obstruction, aortic, 347 
mitral, 347 
of bile duct, 270 
of oesophagus, 552 
of intestine, 415 
| Occlusion of vagina, 31, 705 
Ocular headache, 331 

paralysis, 587 
O'Donnell's diabetic bread, 177 
(Edema, 78, 352 

of .larynx, 442 

of lungs, 78, 352 

phlebitic, 633 
Oertel's treatment of obesity, 342, 546 
(Esophagotomy, 552 
CEsophagus, cancer of, 102 

foreign bodies in, 552 

stricture of, 552 
Omentum, hernia of, 361 
Onychia, 553 
Oophoritis, 562 
Operation for cataract, 116 
Ophthalmia, croupous, 138 

granular, 138 

neonatorum, 136 

purulent, 137 

strumous, 136 
Opium habit, 554 

poisoning, 690 
Optic nerve, atrophy of, 28 
Orchitis, 557 
Os calcis, disease of, 561 
Osmidrosis, 80, 615 
Osteomalacia, 511 
Ostitis, 601 

articular, 427 
Otalgia, 219 
Otitis, 219 
Otorrhoea, 561 
Out-knee, 278 



INDEX 



915 



Ovarian dysmenorrhea, 209 
neuralgia, 530 

tumors, 566 
Ovariotomy, 567 
Ovary, inflammation of, 562 

Oxalic acid poisoning, 690 
Oxaluria, 574 
Ozena, 575 



PACK, hot, 73 
Pachymeningitis, 502 
Pagenstecher's ointment, 136 
Paget' s nipple, 542 
Pain, 577 

Painter's colic, 673 
Palate, cleft, 128 

Palmar fascia, contraction of, 202 
Palpitation, 336, 354 
Palsy, wasting, 587 
Pancreas, disease of, 578 
Pannus, 138 

Pancreatized beef-tea, 172 
Papular acne, 20 
Paracentesis from necessity, 237 

in ascites, 55 

in empyema, 235 

in hydronephrosis, 373 

in pleurisy, 667 

of hydrocele, 370 

of ovarian cyst, 567 

of pericardium, 598 
Paralysis, 578 

agitans, 578 

alcoholic, 585 

Bell's 586 

diphtheritic, 198, 580 

facial, 586 

from neuritis, 536 

from progressive muscular atrophv, 
587 

from spinal curvature, 113, 780 

general, of the insane, 584 

hemiplegic, 355 

hysterical, 388 

infantile, 583 

Landry's 513 

lead, 672 

ocular, 587 

paraplegic, 513 

peripheral, 585 

pseudo-hypertrophic, 587 
Paralytic club-foot, 129 
Parametritis, 591 
Paraphimosis, 588 
Paraplegia, 513 
Paronychia, 553, 898 



Parotitis, 512 

Pasteur's lymph, preparation of, 377 

researches in diphtheria, 193 

treatment of rabies, 378 
Payor nocturnans, 538 
Paw's diabetic dietary, 182 
Pediculi, 588 

capitis, 589 

corporis, 590 

pubis, 590 
Pelvic abscess, 591 

cellulitis, 591 

hematocele, 303 

peritonitis, 595 
Pemphigus, 595 
Peptonized enemata, 274, 646 

gruel, 172 

milk, 172 

gruel, 342 
Perforating ulcer of foot, 597 
Perforation in typhoid, 875 

of bowel in hernia, 361 

of stomach and bowels, 276, 610, 87 

of tympanic membrane, 220 
Perforative otorrhcea, 562 

peritonitis, 610 
Pericardium, dropsy of, 598 
Pericarditis, 599 
Perihepatitis, 600 
Perinephritis, 600 
Perineum, fistula of, 886 

rupture of, 600 
Periostitis, 601 
Peripheral paralysis, 585 
Peritonitis, acute, 603 

chronic, 609 

from rupture of liver, 455 

pelvic, 595 

perforative, 610 

puerperal, 729 

tubercular, 611 

in typhoid, 875 
Peritvphlitic abscess, 614 
Perityphlitis, 612 
Pernicious anaemia, 40 
Peroxide of iron, preparation of, 683 
Perspiration, excessive, 615 

offensive, 80 
Pertussis, 617 
Pessaries, 564, 703, 890 
Petit mal, 250 
Phagedena, 271 
Phagocytosis, 854 
Pharyngeal cough, 154 

grattage, 628 
Pharyngitis, 625 ,, 

acute, 625 



916 



INDEX 



Pharyngitis, chronic, 626 

granular or follicular, 627 

syphilitic, 629 
Phimosis, 629 
Phlebitic abscess, 632 
Phlebitis, 632 

Phlegmasia alba dolens, 633 
Phlegmon, 255 
Phlegmonous tonsillitis, 833 
Phosphaturia, 635 
Phosphoric acid diathesis, 635 
Phosphorus poisoning, 691 
Photophobia, 136, 150 
Phthiriasis, 636 
Phthisical cough, 153 
Phthisis, 636 

abdominal, 611 

Koch's remedy for, 850 

Lannelongue's remedy for, 858 

laryngeal, 439 

Le Peine' s remedy for, 856 

Liebreich's remedy for, 857 

Keichet's remedy for, 857 

Tranjen's remedy for, 857 
Physostigmine poisoning, 688 
Piles, 320 

internal, 322 
Pilocarpine poisoning, 691 
Pityriasis rubra, 660 

versicolor, 661 
Placenta previa, 661 

retained, 243 
Plaster-of-Paris jacket, 114 
Plaster splints for club-foot, 130 
Plethoric amenorrhoea, 32 
Pleurisy, 663 

dry, 671 
Pleuritis, 663 
Pleurodynia, 671 
Pleuro-pneumonia, 673 
Plumbism, 672 

amblyopia of, 30 
Pneumatic treatment of bronchitis, 88 
Pneumonia, 673 
Pneumonotomy, 466 
Pneumothorax, 679 
Poisoned wounds, 777, 900 
Poisoning, .680 

ursemic, 73 
Poliomyelitis, anterior acuta, 583 
Polypi/ 692 

nasal, 693 

of ear, 222 

uterine, 505 
Polyuria, 174, 694 
Poroplastic felt jacket, 114 
Post-partum hemorrhage, 315 



Potash poisoning, 691 
Pott's curvature, 113 
Pregnancy, amblyopia of, 30 

disorders of, 695 

extra-uterine, 262 

mole, 510 
Primary syphilis, 812 
Procidentia, 702 
Proctitis, 698 

Profuse menstruation, 504 
Prolapse of anus, 699 

of bladder, 703 

of ovary, 210 

of rectum, 699 

of uterus, 702 

of vagina, 703 
Prostate, enlarged, 706 

inflamed, 705 
Prostatitis, 705 
Prurigo, 710 
Pruritus, 711 

. of anus, 49 
Prussic acid poisoning, 682 
Pseudo hypertrophic paralysis, 587 
Psoas abscess, 714 
Psoriasis, 715 

of tongue, 844 
Ptyalism, 721 
Puerperal convulsions, 722 

fever, 725 

mania, 729 

peritonitis, 729 
Pulmonary ailments in measles, 492 

embarrassment in cardiac disease, 
352 

hydatids, 369 

phthisis, 636 
Pumping the liver, 269 
Purpura, 731 

hemorrhagica, 732 
Purulent catarrh of ear, 221 

dropsy of pericardium, 598 

expectoration, 88 

lymphadenitis, 479 

ophthalmia, 137 

otorrhoea, 561 

periostitis, 602 

pleurisy, 670 
Pustule, malignant, 482 
Pveniia, 732 
Pyelitis, 734 
Pyelonephritis, 736 
Pylorus, cancer of, 103 

obstruction of acidity in, 16 

removal of, 103 
Pyonephrosis, 736 
Pyo-pneumothorax, 736 



INDEX. 



917 



Pyosalpinx, 737 
Pyothorax, 2 3 5 
Pyrexia. 675 
Pyroasis, 16, 210 



Q 



UINSY, 831 



RABIES, 374 
Rachitis, 759 
Radical cure of hernia, 361 
of hydrocele, 370 
Ranula, 738 
Rapid heart, 336 
Raynaud's disease, 739 
Recent hernia, 356 
Rectum, cancer of, 105 

inflammation of; 69S 

prolapse of, 699 

strictute of, 105 
Reflex headache, 330 
Reichet's treatment of tubercle, 851 
Relapsing fever, 739 
Relaxed sore-throat, 626 
Remittent fever, 740 
Renal calculi, 787 

colic, 787 

disease, 72, 512, 736 

dyspepsia, 214 

hematuria, 306 

hemorrhage, 78 
Resection of lung, 655 

of ribs, 237 
Retained placenta, 243 
Retention of urine, 741 
in typhoid, 875 
Retinal asthenopia, 55 

detachment, 743 
Retinitis, 742 

Retroflexion of uterus, 889 
Retroversion, 890 
Rheumatic arthritis, 743 

endocarditis, 239 

fever, 747 

iritis, 423 

laryngitis, 439 

synovitis, 809 
Rheumatism, acute, 747 

chronic, 753 

gonorrhoea^ 757 

muscular, 758 
Rickets, 759 
Rigor, 762 
Ringworm, 836 
Roberts's diabetic dietary, 182 



Rodent ulcer, 763 

Roseola, 764 

Rotheln, 764 

Round worms, 53 

Rubeola, 489 

Rupia, 764 

Rupture, 356 

of Fallopian tube, 262 

of liver, 455 

of perineum, 600 



(JACRO-ILIAC joint disease, 765 
O Salicylic treatment of endocarditis, 
240 
of rheumatism, 747 
Saline injections, 38 
Salisbury's treatment of obesity, 54? 
Salivation, 721 
Sarcinse, 765 
Say re's jacket, 115 

suspension, 459 
Scabies, 765 
Scalds, 95 
Scarification of acne rosacea, 22 

of gums, 149 

of ulcers, 882 
Scarlatina, 767 
Scavenger muscles, 87 
Schrot's treatment of obesity, 548 
Sclerema neonatorum, 771 
Scleroderma, 771 
Sclerosis, disseminated, 772 
Sclerotitis, 771' 
Sciatica, 521, 770 
Scorbutic purpura, 731 
Scorbutus, 775 
Scraping cancer, 108 

carbuncle, 111 

joints, 430 

lupus, 476 

ulcer, 882 
Scrofula, 773 
Scurvy, 775 

Scybalae causing diarrhoea, 148 
Sea-sickness, 775 
Sebaceous cysts, 777 
Seborrhoea, 166 
Seborrhoeic acne, 20 

eczema, 231 
Secondary syphilis, 813 
Seegen's diabetic dietary, 183 
Seibert's treatment of diphtheria, 195 
Seminal emissions, 778 
Senile cataract, 117 

gangrene, 271 
Septicaemia, 777 



918 



INDEX 



Sequestra, removal of, 520 
Shingles, 362 
Shock, 134 

from burns, 95 
Sick room in exanthemata, 489 
Sigmoid flexure, volvulus of, 421 
Silver nitrate poisoning, 691 
Simple cerebral meningitis, 497 

diarrhoea, 186 
Sinus in lymphadenitis, 480 

in mammary abscess, 487 
Skin grafting, 882 
Sleeplessness, 402 

in cardiac disease, 353 

in insanity, 402 

in opium habit, 555 
. in typhoid fever, 872 
Sloughing bedsores, 65 

piles, 321 

ulcer, 885 
Smallpox, 884 
Sneezing, 118 
Soap solution, Hebra's, 19 
Soda poisoning, 691 
Soft cataracts, 116 

corns, 152 
Sore nipples, 539 

-throat, 831 

relaxed, 626 
Sounding for stone, 790 
Soya bread, 178 
Spasm of accommodation, 56 

laryngeal, 437 
Spasmodic cough, 156 

croup, 158, 437 

dysmenorrhea, 205 

laryngitis, 157 
Spermatorrhoea, 778 
Spina bifida, 778 
Spinal caries, 113 

curvature, 113, 779 

paralysis from, 113, 780 

meningitis, 501 
Spirone, 91 

Splenic leukaemia, 445 
Sponge grafting, 882 
Spongy gums, 787 
Spontaneous gangrene, 739 
Sprains, 780 
Spurious croup, 156 
Squinting, 781 
Stabile galvanization, 585 
Stammering, 783 
Starvation, 783 
Static bath, 388 
Sterility, 784 
Sterilizing milk, 187 



Stimulants for gout, 296 

Stings, 785 

Stomach, cancer of, 102 

diseases of, 785 

hemorrhage from, 301 

perforation of, 274, 610 

pump, 681 

ulcer of, 272 
Stomatitis, 785 

aphthous, 51 

gangrenous, 108 
Stone in the bladder, 790 

in gall-bladder, 268 

in the kidney, 787 

in the urethra, 794 
Strabismus, 782 

Stramonium poisoning, 684, 690 
Strangulated hernia, 357 
Strangury, 795 
Strapping carbuncle, 111 

chest, 665 
. ulcer, 882 
Stricture of gullet, 102, 552 

of intestines, 416 

of nasal duct, 253 

of rectum, 105 

of urethra, 795 
Stridulus laryngitis, 155 
Strophanthus in heart disease, 345 
Strophulus, 802 
Struma, 773 
Strumous ophthalmia, 136 

peritonitis, 610 
Strychnine in alcoholism, 27 

in delirium tremens, 170 

poisoning, 691 
Sty, 802 

Submammary abscess, 485 
Subinvolution, 509 
Sublimate gelatin, 230 
Subplantar corns, 153 
Suffocation, 803 

from emphysema, 235 

from goitre, 284 
Sugar of lead poisoning, 689, 692 
Summer diarrhoea, 187 
Sunburn, 121 
Sunstroke, 803 
Sulphuret poisoning, 692 
Sulphuric acid poisoning, 682 
Suppositories, nutrient, 274 
Suppression of urine, 804 
Suppurating piles, 320 
Suppuration, 12 

in hip-joint disease, 365 ' 

in mumps, 512 
Suppurative haematocele, 306 



INDEX. 



919 



Suppurative hsematoma, 306 

iritis, 423 

orchitis, 559 

pelvic cellulitis, 593 

peritonitis, 609 

phlebitis, 632 

synovitis, 809 
Supra-orbital neuralgia, 524 

-pubic lithotomy, 793 

-renal capsules, diseases of, 23 
Suralirnentation, 639 
Suspension, 459 
Sweating, 615 

bloody, 302 

night-, 659 
Sycosis, 805 

Sylvester's artificial respiration, 201 
Symblepharon, 80S 
Svmpathetic iritis, 423 
Syncope, 353, 808 

from hemorrhage, 313 
Synovitis, 809 
Syphilis, 810 
Syphilitic abortion. 9 

baldness, 64 

ear disease, 222 

glossitis, 284 

iritis, 423 

laryngitis, 442 

liver disease, 456 

meningitis, 498 

onychia, 554 

orchitis, 559 

ostitis, 603 

ozsena, 5 1 1 

periostitis, 602 

pharyngitis, 629 

rash, 316 

synovitis, 809 

ulcers, 810, 883 
Syphoning, 235 



TABES dorsalis, 456, 598 
mesenterica, 507, 773 

Taenia solium, 823 

Talipes, 129 

Tapeworm, 822 

Tapping ascites, 55 
in empyema, 235 
in hydrocele, 370 
in hydronephrosis, 373 
in ovarian cyst, 567 
in pericardium, 597 
in pleurisy, 667 

Tartar emetic poisoning, 683 

Taxis, abdominal, 418 



Taxis, hernial, 358 
Teething, 173 
Tender nipples, 539 
Tenesmus, 826 
Tertiary syphilis, 818 
Testicle, diseases of, 827 

inflammation of, 557 
Tetanus, 827 

neonatorum, 830 
Tetany, 830 
Thoracentesis in empyema, 235 

in pleuritis, 668 

in pneumothorax, 680 
Thoracic aneurism, 41 
Thread-worm, 830 
Throat, sore-, 831 
Thrombosis, 632 
Thrombus in endocarditis, 240 

in phlebitis, 632 

in phlegmasia, 633 
Thrush, 786 
Thyroid gland diseases, 283 

transplantation, 515 
Tic-douloureux, 835 
Tinea, 835 

circinata, 835 

favosa, 263 

kerion, 841 

sycosis, 805 

tarsi, 70 

versicolor, 661 
Tinnitus aurium, 222, 841 
Tobacco amaurosis, 29 

amblyopia, 29 

poisoning, 690, 692 
Toe-nail, ingrown, 398 
Tongue, amputation of, 842 

cancer of, 101 

diseases of, 842 

hvpertrophv of, 843 

inflammation of, 283, 843 

neuralgia of, 843 

syphilitic, 843 

-tie, 845 

ulceration, 843 
Tonsillitis, acute, 833 

erythematous, 833 

follicular, 831 

phlegmonous, 833 
Tonsils, abscess of, 833 

enlargement of, 834 

inflamed, 834 
Toothache, 845 
Torticollis, 846 

Tower-Smith treatment of obesity, 548 
Tracheal catheterism, 198 
Tracheotomy, 164 



920 



INDEX. 



Tracheotomy in croup, 164 

Trachoma, 139 

Trance, 848 

Tranjen's treatment of tuberculosis, 857 

Transfusion, 37 

in diabetic coma, 181 

in yellow fever, 901 

of blood, 37 

of saline solution, 38 
Traumatic delirium tremens, 171 

gangrene, 272 
Trichiasis, 245, 849 
Trichinosis, 849 
Trichophyton tonsurans, 835 
Trismus, 827 

neonatorum, 830 
True croup, 158 
Trusses, 356 
Tubal pregnancy, 262 
Tubercular abscess, 15' 

disease of bones, 852 
of joints, 852. 
of lymphatic glands, 773 
of skin, 470 

laryngitis, 439 

meningitis, 502 

peritonitis, 611 
Tuberculin, 850 
Tuberculosis, 850 

Tuffnell's treatment of aneurism, 41 
Tumors, 859 

ovarian, 566 
Tunica vaginalis, hematocele of, 303 
hydrocele of, 370 
incising, 371 
Tylosis of tongue, 854, 859 
Tympanic membrane, perforation of, 

220 
Tympanites, 860 

after ovariotomy, 571 

in peritonitis, 609 
Typhlitis, 612 
Typhoid fever, 860 
Typhus fever, 876 



TTLCER of anus, 46 






callous, 881 
cancerous, 101 
eczematous, 886 
gastric, 273 
healthy, 879 
indolent, 881 
inflamed, 884 
irritable, 884 
leprous, 444 
lupoid, 469 



Ulcer of cornea, 138, 150 

of foot, perforative, 597 

of mouth, 51, 786 

on feet, 82 

ozsenic, 577 

rodent, 763 

scorbutic, 775 

scrofulous, 773 

simple, 879 

sloughing, 885 

syphilitic, 811, 883 

varicose, 885 

venereal, 810 

weak, 880 
Ulcerated chilblains, 120 

nipple, 541 

onychia, 553 

os or cervix uteri, 565, 888 

sore-throat, 831 
Ulceration of lupus, 469 

of intestines, 658 

of tongue, 843 
Ulcerative endocarditis, 241 

stomatitis, 785 
Ulcers, 879 
Umbilical hernia, 357 
Unripe cataracts, 118 
Uremia, threatening, 73 
Uremic convulsion, 78 

dyspnoea, 78 
Urethra, dilatation of, 796, 797 

divulsion of, 798 

stricture of, 795 
Urethral calculi, 794 

hematuria, 306 

hemorrhage, 800 
Urethrotomy, external, 800 

internal, 799 
Urinary fistula, 886 
Urine, alkalinity of, 635 

diabetic, estimation of, 185 

diminished acidity of, 635 

incontinence of, 393 

retention of, 741 

suppression of, 804 
Urticaria, 260 
Uterine displacements, 888 

headache, 331 

hemorrhage, 107, 315, 504 

myoma, 505 

neuralgia, 522 

polypi, 505, 694 
Uterus, cancer of, 106 

diseases of, 888 

fixation of, 705 

inflammation of, 241, 509 

prolapse of, 702 



INDEX 



921 



'01 



•t. 339 



of, 



\'A(tIXA, occlusioD of, 31 
prolapse of, 703 
Vaginismus, 892 
Valvular disease of 1 

Varicella, 893 
Varicocele, 893 
Varicose ulcer, 885 

veins. 884 
Variola, 884 

Venereal diseases, 288, 810 
Venous hemorrhage, 314 
Veratrin poisoning, 682, 692 
Vermiform appendix, inflammation 

612 

Version of uterus. 24:\ 
Vertebrae, caries of, 1 1 3 
Vertigo, 222, 842 
Vesical calculi, 790 

hematuria, 306 
Vienna paste, 473 

Visceral congestion in cardiac disease, 
352 

neuralgia, 525 
Vision, dimness of, 29 

yellow, 53 
Vitiligo, 444 

Vlerninckx's solution, 765 
Vogel's dietary, 545 
Volvulus, 421 
Vomiting in Bright's disease, 78 

in cancer, 103 

in cholera, 122 

in diarrhoea, 186 

in dyspepsia, 216 

in gastric ulcer, 274 

in meningitis, 498 

in pertussis, 618 

in sea-sickness, 775 

of pregnancy, 695 



WALES'S poultice, 608 
Warte, 897 

Washing out the bladder, 6" 



Washing out the uterus, 509 
Wasp stings, 785 
Wasting palsy, 587 

Water (lint) treatment of obesity, 5-17 
Wax in ear. 219 
Waxy kidney, 7'.' 

liver, 452 
Weir Mitchell's treatment of hvsteria, 
385 
treatment of obesity, 541 
suspension treatment, 460 
Wens, 777 
Wheelhouse's operation for stricture. 

801 
White mixture, 224 
Whitlow, 898 
Whooping-cough, 617 

in measles, 492 
Wine whey, 492 
A V inter residences, 92 
Woltering's diabetic bread, 177 
Wool sorters' disease, 482 
Worms, round, 53 

tape-, 822 

thread-, 830 
Wounds, 899 

contused, 900 

uunshot, «mi;i 

incised, 900 

lacerated, 900 

poisoned, 900 
Wo v en-rubber bandage, 879 
Wry neck, 847 



y ELLOW fever, 900 
I vision, 53 
Yeo's dietary in phthisis, 639 
treatment of obesity, 549 



Z1XC chloride treatment of tubercle, 
i 858 



salts, poisoning by, 692 



59 



